Notice of Privacy Practices

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.

You have the right to obtain a paper copy of this Notice upon request.

This Notice describes the privacy practices of Community Medical Center and the physicians who provide services to patients at this Facility.

Patient Health Information

Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, Treatment, and related medical information. Your Health Information also includes Payment, billing, and insurance information.

How We Use Your Patient Health Information

We use Health Information about you for Treatment, to obtain Payment, and for Health Care Operations, including administrative purposes and evaluation of the quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your permission.

Examples of Treatment, Payment, and Health Care Operations

Treatment: We will use and disclose your Health Information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other Health Care Providers who are participating in your Treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.

Payment: We will use and disclose your Health Information for Payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of Treatment. We will submit bills and maintain records of Payments from your Health Plan. If you have a legal claim against a third party for causing your injuries, we may file a Facility lien in court to collect Payment from them.

Health Care Operations: We will use and disclose your Health Information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of Treatment, and to assess the care and outcomes of your case and others like it.

Special Uses

We may use your information to contact you with appointment reminders. We may also contact you to provide information about Treatment alternatives or other health-related benefits and services that may be of interest to you.

Other Uses and Disclosures

We may use or disclose identifiable Health Information about you for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out Health Information without your permission for the following purposes:

• Required by Law: We may be required by Law to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.
• Public Health Activities: As Required by Law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.
• Health oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.
• Judicial and administrative proceedings: We may disclose information in response to an appropriate subpoena or court order.
• Law enforcement purposes: Subject to certain restrictions, we may disclose information required by Law Enforcement Officials.
• Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.
• Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to Correctional Institutions or for national security purposes.
• Research: We may use or disclose information for approved medical Research.
• Workers Compensation: We may release information about you to workers compensation agencies and your employer to provide benefits for work-related injuries or illness.
• Fundraising: We may contact you, or allow an institutionally-related foundation to contact you, for fundraising purposes. You have the right to opt out of receiving any fundraising communications.

We may also ask if we can disclose limited information about you to clergy or include it in the Facility directory. Under limited circumstances, we may disclose information to notify or locate your relatives or to assist disaster relief agencies. Most uses and disclosures of psychotherapy notes, uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of medical information will only be made with your written authorization. In any other situation not described in this Notice, we will ask for your written authorization before using or disclosing any identifiable Health Information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and Disclosures.

Individual Rights

You have the following rights with regard to your Health Information. Please contact the person listed below to obtain the appropriate form for exercising these rights.

• Request Restrictions: The Facility is not required to grant a request for restrictions in all circumstances. However, the Facility must agree to a request for a restriction on the Disclosure of Protected Health Information to a Health Plan, or a Business Associate of a Health Plan, if the Disclosure is for the purposes or carrying out Payment or Health Care operation and is not otherwise Required by Law; and the Facility is paid out of pocket in full. In regards to other requests, restrictions will be granted only as follows: (a) it is the facility’s policy not to agree to any restrictions on uses or Disclosures for Treatment or Health Care Operations, except as stated above. The Privacy Officer must approve any exceptions in writing; (b) the facility is not allowed to grant requests to restrict Disclosures required for public health, law enforcement, or to comply with any other laws or regulations.
• Confidential Communications: You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.
• Inspect and Obtain Copies: In most cases, you have the right to look at or get a copy of your Health Information. There may be a charge for the copies based on state established rates.
• Amend Information: If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct the existing information or add the missing information.
• Accounting of Disclosures: You may request a list of instances where we have disclosed Health Information about you.

Our Legal Duty

We are required by Law to protect and maintain the privacy of your Health Information, to provide this Notice about our legal duties and privacy practices regarding Protected Health Information, to notify you of any breach of your Health Information that we are required by law to report, and to abide by the terms of the Notice currently in effect.

Changes in Privacy Practices

We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the admissions area. You can also request a copy of our Notice at any time. For more information about our privacy practices, contact the person listed below.

Complaints

If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below will provide you with the appropriate address upon request. You will not be penalized in any way for filing a complaint.

Contact Person

If you have any questions, requests, or complaints, please contact the Facility Privacy Officer at: 406-327-4040

Independent Contractors

Community Medical Center and the physicians who practice here are independent contractors and do not hereby assume any liability for the services or conduct of the other.