Notice of Privacy Practices: Your information, your rights, our responsibilities.

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.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
  We will let you know if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Uses and Disclosures

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 to run our clinical practice and make sure that you and our other patients receive quality care. 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.

Business Associates: There are some services provided in our organization through contracts with business associates. For example, the copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

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, Treatments, Services: 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, contact our Privacy Officer at (218) 878-7667.

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.

Organ and Tissue Donation: If you are an organ donor, we may disclose health information to organ procurement organizations.

Coroner, Medical Examiner or Funeral Director: We may disclose health information to a coroner, medical examiner, or funeral director. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court order.

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 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.

Your Health Information Rights

Right to Inspect and Copy

You have the right to review, inspect and receive a copy of any/all portions of your health information. If your health information is maintained in electronic format, you have the right to request an electronic copy. You must submit your request in writing. To inspect or request copies of your health information contact our Privacy Officer. We may charge a cost-based fee.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health 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

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 and if this occurs, you will be notified of the reason for denial. Your request must be made in writing. To request an amendment, contact our Privacy Officer.

Right to Request Restrictions

You have the right to request a restriction or limitation on the use of your health 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 Privacy Officer

In your request, you must tell us:

• What information you want to limit:
• Whether you want to limit our use, disclosure or both; and
• To whom you want the limits to apply

If you pay for a service or health care item out-of-pocket in full, you have the right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations.

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. To request confidential communications, you must make your request in writing to our Privacy Officer.

Right for an Accounting of Disclosures

You have a right to request an accounting of certain disclosures of your health information for purposes other than treatment, payment, and health care operations or for which you provided written authorizations for six years prior to the date you ask. You must submit your request in writing. To request an accounting of disclosures, contact our Privacy Officer.

Right to Breach Notification

You have the right to notification of a breach of unsecured protected health information.

Right to a Paper Copy of this Notice

You have the right to possess a paper copy of this Privacy Notice. 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.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Your right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Include your information in a hospital directory
• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Changes to this Notice

We reserve the right to change this notice. The new notice will be available upon request, in our registration office, and on our web site.

Complaints

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.

Privacy Officer
Community Memorial Hospital
512 Skyline Boulevard
Cloquet, MN 55720
Phone: (218) 878-7667

This notice is effective as of April 14, 2003. Revised October 2011 and September 2013