Notice of Privacy Practices

Notice of Privacy Practices


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.

For Payment. 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 payor, 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; and
  • determine how to continually improve the quality and effectiveness of the health care we provide.

Appointments. 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.

Fund Raising. CMH may use your information to contact you to raise funds for the CMH Foundation. If we use your PHI for fundraising, you have the right to opt out of receiving such communications and may inform us not to contact you again for this purpose.

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; and
  • to assist law enforcement officials in their law enforcement duties;

Public Health & Safety Issues. 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, helping with product recalls, reporting adverse reactions to medications, to report suspected abuse, neglect or domestic violence; or to prevent or reduce a serious threat to the health or safety of you or any other person.

Decedents. Health information may be disclosed to funeral directors, medical examiners, or coroners to enable them to carry out their lawful duties.

Organ & Tissue Donation. Your health information may be used or disclosed for eye or tissue donation purposes.

Research. 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.

Law Enforcement & Government Functions. Your protected health information may be used or shared for law enforcement purposes or with a law enforcement official, with health oversight agencies for health oversight activities authorized by law, and for special government functions such as military, national security, and presidential protective services.

Workers' Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers' Compensation.

Hospital Directory. Unless you instruct us not to, we may include limited information about you in the hospital directory while you are a patient.  This information may include your name, location in the hospital, and your general condition (e.g., fair or stable). This directory information may be released to people who ask for you by name so that they may generally know how you are doing. If you do not want this information shared please let us know. Also, your religious affiliation may be given to a member of the clergy even if they do not ask for you by name.

Family, Friends, and Notification Purposes. Unless you indicate otherwise, we may disclose your protected health information to family members, friends, or others you identify to the extent it is relevant to their involvement with your care or payment for your care, or to let them know about where you are and your condition. We may also use or disclose your information to an organization to assist in disaster relief efforts. We will provide you with an opportunity to agree to or prohibit or restrict the use or disclosure.  If you are not present or are unable to agree due to your incapacity or emergency circumstances we may disclose your PHI as necessary if we determine that it is in your best interests, based on our professional judgment.  Although we must be able to speak with your other physicians or health care providers, please let us know if we should not speak with other individuals, such as your spouse or family.

With Your Written Permission Except in limited circumstances, we must obtain your written authorization to use or disclose psychotherapy notes about you and to use or disclose your PHI for marketing purposes.  We must also obtain an authorization for any disclosure of PHI that would constitute a sale of your protected health information.  In addition, certain disclosures of any drug and alcohol abuse treatment records may require your prior written authorization. We will not use or share your information other than as described in this notice unless you tell us we can in writing.  If you give us an authorization, you have the right to change your mind and revoke it.  This must be in writing and submitted to the privacy officer at the address listed below.  We cannot take back any uses or disclosures already made with your authorization. 

Other uses. 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:

Right to Request Restrictions.  You have the right to ask for restrictions in the ways in which we use and disclose your PHI for treatment, payment, health care operations and to individuals involved in your health care or payment for your health care.  We are not required to agree to your request.  If, however, you pay for a service or health care item in full out-of-pocket, you can ask us not to share that information with your health plan for the purpose of payment or health care operations.  In that case, we must agree to such a request unless a law requires us to share that information.  If we agree to a request, we will comply with your request unless the information is needed to provide you emergency treatment or until the restriction is terminated.  To request a restriction, you must make your request in writing at the time you register or submit your request to the Privacy Officer or Health at the address listed at the end of this Notice.  Include in your request what information you want to restrict, whether you want to restrict use, disclosure or both, and to whom you want the limits to apply – for example, disclosures to your spouse.  

Right to Request Confidential Communications.  You have the right to request that you receive communications containing your PHI from us by alternative means or at alternative locations.  For example, you may ask that we only contact you at home or by mail.  To request confidential communications, you must make your request in writing at the time you register or submit the request to the Privacy Officer at the address listed at the end of this Notice.  Specify in your request how or where you wish to be contacted.  We will accommodate all reasonable requests.

Right to Inspect and Copy.  Except under certain circumstances, you have the right to inspect and obtain an electronic or paper copy of your medical records, billing records, and records used to make decisions about your care.  Please contact our Health Information Management Department or the Privacy Officer at the phone number below to ask us how to do this.  We will provide a copy or a summary of your health information, usually within 30 days of your request.  We may charge a reasonable, cost-based fee.  In some cases, we may deny your request as permitted by law.  Except under certain circumstances, you may request the denial be reviewed by another licensed health care professional chosen by us.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

Right to Amend.  If you believe that PHI in your records is incorrect or incomplete, you have the right to ask us to amend your record.  Your request must be in writing, submitted to the Privacy Officer at the below address and provide a reason to support the requested amendment.  We may deny your request for a number of reasons including if it is not made in writing and does not include a reason to support the request or requests amendment of information not created by us; is not part of the records used to make decisions about your care; is not part of the information you would be permitted to inspect and copy; or is accurate and complete.  If we deny your request, we will tell you in writing why, usually within 60 days.

Right to an Accounting of Disclosures.  You have a right to ask for a list of instances when we have disclosed your PHI for reasons other than for treatment, payment, health care operations, disclosures made with your authorization and for certain other limited purposes.  To request an accounting of disclosures, your request must be in writing and include the specific time period (which may not be longer than six years prior to the date of your request) of the accounting.  Submit the request to the Privacy Officer at the address below.  If you ask for this information from us more than once every twelve months, we may charge you a fee.  You will be notified in advance of the cost so that you may choose to withdraw or modify your request before incurring a cost.

Right to Receive Notice of a Breach.  You have the right to be notified following a breach of your unsecured PHI.

Right to Receive a Copy of Notice of Privacy Practices.  You have the right to a copy of this Notice in paper form, even if you have agreed to receive this Notice electronically.  You may ask us for a copy at any time. To request a copy of this Notice, please contact the Privacy Officer. 


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; and

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 News Tribune
  • On our website at
  • Posted within the facility
  • Revised Notice of Privacy, for which you must sign a receipt.

Contact Information:

If you have any questions or complaints, please contact:

Community Memorial Hospital Privacy Officer
208 Columbus Street, Hicksville, OH 43526

Phone: 419-542-5589 (direct line)


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