CRAWFORD COUNTY MEMORIAL HOSPITAL
Denison, Iowa

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.

Effective Date: 04-14-03

If you have any questions about this notice, please contact the Privacy Officer.

PURPOSE OF THE PRIVACY NOTICE
The Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, initiate payment or conduct health care operations and for other purposes that are permitted or required by law. The Crawford County Memorial Hospital reserves the right to make changes in the Notice of Privacy Practices. This notice describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services
WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices of our hospital and that of
         Any health care professional authorized to enter information into your
            medical record
         All employees and departments of the hospital as well as any member of a
            volunteer group we allow to help you while you are in the hospital
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor.
WE ARE REQUIRED BY LAW TO:
         Make sure that medical information that identifies you is kept private
         Provide you this notice of our legal duties and privacy practices regarding
           your medical information
         Follow the terms of this notice that is currently in effect. We may change
           the terms of our notice at any time. The new notice will be effective for all
           protected health information that we maintain at that time. Upon your
           request, we will provide you with any revised Notice of Privacy Practices.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
Examples of each category are included. Not every use or disclosure in each category is listed, however all of the ways we are permitted to use and disclose information falls into one of these categories.
FOR TREATMENT: We may use medical information about you to provide, coordinate or manage your medical treatment or services. We may disclose medical information about you to other physicians or health care providers who are or will be involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the services you need such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved
in your medical care after you leave the hospital, such as family members, clergy or others we use to provide services that are part of your care.
          FOR PAYMENT: We may use and disclose medical information about you so that treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment
         FOR HEALTHCARE OPERATIONS: We may use and disclose as needed medical information about you for hospital operations. These uses and disclosure are necessary to manage the day to day operations of the hospital and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, medical students and other hospital personnel for review and learning purposes. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital. We may share your protected health information with business associates that perform various activities for the hospital (e.g., billing services). Whenever an arrangement between the hospital and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. 
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES
     TREATMENT ALTERNATIVES, HEALTH-RELATED BENEFITS AND SERVICES: We may use and disclose medical information to tell you about treatment alternatives, health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about the hospital and the services that the hospital offers. You may contact our Privacy Officer to request that these materials not be sent to you.
     FUNDRAISING ACTIVITIES: We may use contact information such as your name, address, telephone number and the dates that you received healthcare services at the hospital to raise money for the hospital and its operations. We may disclose this information to the hospital foundation so that the foundation may contact you. If you do not want the hospital to contact you for fundraising efforts, you must notify the Privacy Official in writing.
    HOSPITAL DIRECTORY: We may include limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, general condition such as fair, stable etc. The directory information may be released to people who ask for you by name unless you have requested a restriction on the release of this information.
   INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: We may release information to a family member or friend who is involved in your medical care. We may also give information to someone who helps pay for your care.
   RESEARCH: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. We will almost always ask for your specific permission if the research will have access to your name, address or other information that identifies who you are.
    REQUIRED BY LAW: We will disclose medical information about you when required to do so by federal, state or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosure would only be to someone able to help prevent the threat.
ORGAN AND TISSUE DONATION, CORONERS AND FUNERAL DIRECTORS: If you are an eye, organ or tissue donor, we may release medical information to an organ donor organization to facilitate organ and tissue donation and transplantation. We may disclose medical information to a coroner or medical examiner for identification purposes, to determine cause of death and to perform other duties authorized by law. We may release medical information to funeral directors as necessary to carry out their duties.
PUBLIC HEALTH: We may disclose your protected health information for public health activities. These activities generally include the following
               To prevent or control disease, injury or disability
               To report births and deaths
               To report child abuse or neglect
               To report reactions to medications or problems with products
               To notify people of recalls of products they may be using
               To notify a person who may have been exposed to a disease or may
                  be at risk for contracting or spreading a disease or condition
               To notify the appropriate government authority if we believe a patient
                  has been the victim of abuse, neglect or domestic violence. This
                  disclosure will be made consistent with the requirements of applicable
                  federal and state laws.
                 HEALTH OVERSIGHT: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights.
                               LEGAL PROCEEDINGS: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful purpose.
                               LAW ENFORCEMENT: We may disclose medical information, so long as legal requirements are met, for law enforcement purposes including:
             In response to a court order, subpoena, summons or similar process
             To identify or locate a suspect, fugitive, material witness or missing
                person
             Pertaining to victims of a crime
             Suspicion that death has occurred as a result of criminal conduct
             About criminal conduct at the hospital
             In emergency circumstances to report a crime, the location of the
                crime or victims or the identity, description or location of the person
                who committed the crime. 
         WORKER’S COMPENSATION: We may disclose your protected health information as authorized to comply with worker’s compensation laws and other similar legally established programs.
         INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement agency. 
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
        RIGHT TO INSPECT AND COPY: You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records but does not include psychotherapy notes. Under federal law, you may not inspect or copy information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
We may deny your request to inspect and copy in certain limited circumstances. You may request that the denial be reviewed. Contact the Privacy Officer if you have questions about access to your medical record.
       RIGHT TO AMEND: You may request an amendment of protected health information about you. You have a right to request an amendment for as long as the hospital maintains this information. The request to amend must be in writing. We may deny your request for amendment. If denied, you may file a statement of disagreement and we may prepare a rebuttal to your statement and provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
       RIGHT TO AN ACCOUNTING OF DISCLOSURES: This right applies to disclosures for purposes other that treatment, payment or healthcare operations as described in this Notice of Privacy Practices and that occurred after April 14, 2003. It excludes disclosures we may have made to you, for the hospital directory, to family members of friends involved in your care or for notification purposes.
      RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction on the medical information we use or disclose about you for treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request. If we do agree, we will restrict your protected health information unless it is needed to provide emergency treatment.
      RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request to receive confidential communications by alternative means or at an alternative location. We are not required to agree to your request. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will accommodate reasonable requests. Your written request must specify how and where you would like to be contacted.
      RIGHT TO A PAPER COPY OF THIS NOTICE: You have a right upon request to receive a paper copy of this notice, even if you have agreed to accept this notice electronically.
COMPLAINTS
If you believe that your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services or by notifying the Privacy Officer at the hospital. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer at 263-1812 for further information about the complaint process

ORGANIZED HEALTH CARE ARRANGEMENT (OHCA)
Crawford County Memorial Hospital (CCMH) is a clinically integrated health care setting where patients receive medical care from hospital personnel and from independent health care practitioners. CCMH and these practitioners need to share medical information to provide care to patients and to conduct health care operations. CCMH and these practitioners, who have privileges to treat patients at the hospital, have agreed to follow uniform practices when using or disclosing medical information related to inpatient or outpatient hospital services. This arrangement is an Organized Health Care Arrangement (OHCA) and only covers information practices for medical services rendered through the Crawford County Memorial Hospital.