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.
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.
For Treatment: We may use your health information to provide you with treatment or services. We may disclose health information about you to doctors, nurses, technicians, students, or other facility personnel who are involved in your care. For example, a doctor treating you may need to know your surgical history to provide quality care. Various services may share health information about you in order to coordinate the care you may need such as lab, x-rays, physical therapy, prescriptions, meals, etc. We may also provide your physician or a subsequent healthcare provider with copies of various reports to assist him or her in treating you.
For Payment: We may use and disclose health information about you for purposes of receiving payment for treatment and services that you receive. For example, we may need to give your insurance company information about your surgery so they will reimburse us for the treatment. We may also disclose your health information to your insurance company about treatment you are going to receive to determine whether your plan will cover it.
For Health Care Operations: We 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 and/or learn how to improve our facility and services.
Required by Law: We may use and disclose information about you as required by law. For example, we may disclose information in the event of an investigation in which you are a victim of abuse, a crime, or domestic violence.
Medical Emergency: We may use and disclose your health information to help you in a medical emergency.
Appointments: We may use your information to provide appointment reminders, treatment options, or other health services that may be of interest to you.
Fundraising: We may contact you for the purposes of raising funds to support facility operations. If you do not want the facility to contact you for fundraising
efforts, you must notify the facility at (218) 879-4641.
Public Health: Your health information may be used or disclosed for public health activities such as assisting public health authorities to prevent or control disease, injury, or disability.
Health Oversight Activities: We may disclose health information to government, licensing, auditing and accrediting agencies for actions allowed or required by law.
Workers Compensation: Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation.
Other Uses of Health Information: Other uses and disclosures not covered by this notice or the laws that apply to use will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. We are unable to take back any disclosures we have already made with your permission.
Right to Request Restrictions
You have the right to restrict the use of your confidential healthcare information. However, the facility may choose to refuse your restriction if it is in conflict with providing you with quality healthcare or in the event of an emergency situation.
You must make your request in writing. To request restrictions, contact our
In your request, you must tell us:
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. (For example, you can ask that we only contact you at work or by mail). We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
You must submit your request in writing. To request confidential communications, contact our Privacy Officer.
Right to Inspect and Copy
You have the right to review, inspect and photocopy any/all portions of your
healthcare information. You must submit your request in writing. To inspect or request photocopies of your healthcare information, contact our Privacy Officer.
If you request a copy of the information, we may charge a fee for the costs of
copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the hospital will review your request. We will comply with the outcome of the review.
Right to Amend
You have the right to request changes to your healthcare information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us
• Is not part of the medical information kept by or for the facility
• Is not part of the information which you would be permitted to inspect and copy
• Is accurate and complete
Your request must be made in writing. To request an amendment, contact our Privacy Officer.
Right for an Accounting of Disclosures
You have a right to know who has accessed your confidential healthcare information and for what purpose. You must submit your request in writing. To request an accounting of disclosures, contact our Privacy Officer.
Your request must state a time period which may be longer than six (6) years and may not include dates before April 14, 2003.
Right to a Paper Copy of this Notice
You have the right to possess a copy of this Privacy Notice upon request. You may ask us to give you a copy of this at any time. You may also obtain a copy of this notice at our website: www.cloquethospital.com
To obtain a copy of this notice, please contact the Registration office or our Privacy officer.
Changes to this Notice
We reserve the right to change this notice. The notice will be posted in the facility and copies of the current notice will be available in registration. In addition, each time you register at or are admitted to the facility for treatment or services, the
current notice in effect will be made available to you.
If you believe your privacy rights have been violated, you may file a complaint with our facility by contacting the Privacy Officer or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Contacting Our Privacy Officer
If you have questions or concerns about our privacy practices and/or this notice, please contact our Privacy Officer.
Community Memorial Hospital
512 Skyline Boulevard
Cloquet, MN 55720
This notice is effective as of April 14, 2003. Revised November 2011.