Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Community Memorial Hospital (CMH) uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of CMH.
How CMH May Use or Disclose Your Health Information
For Treatment CMH may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will be recorded in your medical record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions take by them in the course of your treatment and note how you respond to the actions. CMH may use and disclose your health information to other health care providers who are on the medical staff of CMH. For example, our primary care physicians participate in an “on-call” group with other primary care physicians. If your physician is not available to provide services, the on-call physician may need to access your health information in order to address your health care needs.
CMH may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payer, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of your medical care.
For Health Care Operations
CMH may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:
evaluate the performance of our staff
assess the quality of care and outcomes in your case and similar cases
learn how to improve our facilities and services
determine how to continually improve the quality and effectiveness of the health care we provide
CMH may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
CMH may use your information to contact you to raise funds for the CMH Foundation.
As required by law
CMH may use and disclose information about you as required by law. For example, CMH may disclose information for the following purposes:
for judicial and administrative proceedings pursuant to legal authority
to report information related to victims of abuse, neglect or domestic violence
to assist law enforcement officials in their law enforcement duties
Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.
Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
Your health information may be used or disclosed for eye or tissue donation purposes.
CMH may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.
Health and Safety
Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.
Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.
Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.
Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent CMH has taken action in reliance on such.
Your Health Information Rights
You have the right to:
request a restriction on certain uses and disclosures or your information as provided by 45 C.F.R. §164.522; however, CMH is not required to agree to a requested restriction
obtain a paper copy of the notice of information practices upon request
inspect and obtain a copy of your health record as provided for in 45 C.F.R. §164.524
request that your health record be amended as provided in 45 C.F.R. §164.526
request communications of your health information by alternative means or at alternative locations
receive an accounting of disclosures made of your health information as provided by 45 C.F.R. §164.528
You may complain to CMH and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.
Obligations of CMH
CMH is required by law to:
maintain the privacy of protected health information
provide you with this notice of its legal duties and privacy practices with respect to your health information
abide by the terms of this notice
notify you if we are unable to agree to a requested restriction on how your information is used or disclosed
accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations
CMH reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you by:
Public Notice in the The News-Tribune
Public Notice at the entrances to the facility
Revised Notice of Privacy, for which you must sign a receipt
If you have any questions or complaints, please contact:
Community Memorial Hospital Privacy Officer
208 Columbus Street
Hicksville, OH 43526
Phone: 419-542-5566 (direct line)