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 medical information and to provide you with notice of our legal duties, privacy practices and your rights with respect to your medical information. Medical information includes medical, insurance and medical payment information, such as your diagnosis, medications or medical payment history, which identifies you.

WHO WILL FOLLOW THIS NOTICE

COMMUNITY HOSPITAL.

This Notice describes the privacy practices of Community Hospital (the “Hospital”) and all of its programs and departments, including its rural health clinics.

MEDICAL STAFF.

This Notice also describes the privacy practices of an “organized health care arrangement” or “OHCA” between the Hospital and eligible providers on its Medical Staff. Because the Hospital is a clinically-integrated care setting, our patients receive care from Hospital staff and from independent practitioners on the Medical Staff. The Hospital and its Medical Staff must be able to share your medical information freely for treatment, payment and health care operations as described in this Notice. Because of this, the Hospital and all eligible providers on the Hospital's Medical Staff have entered into the OHCA under which the Hospital and the eligible providers will:

• Use this Notice as a joint notice of privacy practices for all inpatient and outpatient visits and follow all information practices described in this notice;

• Obtain a single signed acknowledgment of receipt; and

• Share medical information from inpatient and outpatient hospital visits with eligible providers so that they can help the Hospital with its health care operations.

The OHCA does not cover the information practices of practitioners in their private offices or at other practice locations.

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The following are the types of uses and disclosures we may make of your medical information without your permission. Medical information includes medical, insurance and medical payment information, such as your diagnosis, medications or medical payment history, which identifies you. Where State or federal law restricts one of the described uses or disclosures, we follow the requirements of such State or federal law. These are general descriptions only. They do not cover every example of disclosure within a category.

Treatment. We will use and disclose your medical information for treatment. For example, we will share medical information about you with our nurses, your physicians and others who are involved in your care at the Hospital. We will also disclose your medical information to your physician and other practitioners, providers and health care facilities for their use in treating you in the future. For example, if you are transferred to a nursing facility, we will send medical information about you to the nursing facility.

Payment. We will use and disclose your medical information for payment purposes. For example, we will use your medical information to prepare your bill and we will send medical information to your insurance company with your bill. We may also disclose medical information about you to other medical care providers, medical plans and health care clearinghouses for their payment purposes. For example, if you are brought in by ambulance, the information collected will be given to the ambulance provider for its billing purposes. If State law requires, we will obtain your permission prior to disclosing to other providers or health insurance companies for payment purposes.

Health Care Operations. We may use or disclose your medical information for our health care operations. For example, medical staff members may review your medical information to evaluate the treatment and services provided, and the performance of our staff in caring for you. In some cases, we will furnish other qualified parties with your medical information for their health care operations. The ambulance company, for example, may also want information on your condition to help them know whether they have done an effective job of providing care. If State law requires, we will obtain your permission prior to disclosing to other providers or health insurance companies for their operations.

Business Associates. We will disclose your medical information to our business associates and allow them to create, use and disclose your medical information to perform their job. For example, we may disclose your medical information to an outside billing company who assists us in billing insurance companies.

Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical services.

Treatment Alternatives. We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fundraising. We may contact you as part of a fundraising effort. We may also disclose certain elements of your medical information, such as your name, address, phone number and dates you received treatment or services, to a business associate or a foundation related to the Hospital so that they may contact you to raise money for the Hospital.

Hospital Directory. We may include your name, location in the facility, general condition and religious affiliation in a facility directory. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. We will not include your information in the facility directory if you object or if we are prohibited by State or federal law.

Family and Friends. We may disclose your location or general condition to a family member or your personal representative. If any of these individuals or others you identify are involved in your care, we may also disclose such information as is directly relevant to their involvement. We will only release this information if you agree, are given the opportunity to object and do not, or if in our professional judgment, it would be in your best interest to allow the person to receive the information or act on your behalf. For example, we may allow a family member to pick up your prescriptions, medical supplies or X-rays. We may also disclose your information to an entity assisting in disaster relief efforts so that your family or individual responsible for your care may be notified of your location and condition.

Required by Law. We will use and disclose your information as required by federal, State or local law.

Public Health Activities. We may disclose medical information about you for public health activities. These activities may include disclosures:

• To a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability;

• To appropriate authorities authorized to receive reports of child abuse and neglect;

• To FDA-regulated entities for purposes of monitoring or reporting the quality, safety or effectiveness of FDA-regulated products; or

• 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.

Abuse, Neglect or Domestic Violence. We may notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law, we will only make this disclosure if you agree.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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 laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if reasonable efforts have been made to notify you of the request or to obtain an order from the court protecting the information requested.

Law Enforcement. We may release certain medical information if asked to do so by a law enforcement official:

• As required by law, including reporting wounds and physical injuries;

• In response to a court order, subpoena, warrant, summons or similar process;

• To identify or locate a suspect, fugitive, material witness or missing person;

• About the victim of a crime if we obtain the individual's agreement or, under certain limited circumstances, if we are unable to obtain the individual's agreement;

• To alert authorities of a death we believe may be the result of criminal conduct;

• Information we believe is evidence of criminal conduct occurring on our premises; and

• 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.

Deceased Individuals. We may release medical information to a coroner, medical examiner or funeral director as necessary for them to carry out their duties.

Organ, Eye or Tissue Donation: We may release medical information to organ, eye or tissue procurement, transplantation or banking organizations or entities as necessary to facilitate organ, eye or tissue donation and transplantation.

Research: Under certain circumstances, we may use or disclose your medical information for research, subject to certain safeguards. For example, we may disclose information to researchers when their research has been approved by a special committee that has reviewed the research proposal and established protocols to ensure the privacy of your medical information. We may disclose medical information about you to people preparing to conduct a research project, but the information will stay on site.

Threats to Health or Safety. Under certain circumstances, we may use or disclose your medical information to avert a serious threat to health and safety if we, in good faith, believe the use or disclosure is necessary to prevent or lessen the threat and is to a person reasonably able to prevent or lessen the threat (including the target) or is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.

Specialized Government Functions. We may use and disclose your medical information for national security and intelligence activities authorized by law or for protective services of the President. If you are a military member, we may disclose to military authorities under certain circumstances. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose to the institution, its agents or the law enforcement official your medical information necessary for your health and the health and safety of other individuals.

Workers' Compensation: We may release medical information about you as authorized by law for workers' compensation or similar programs that provide benefits for work-related injuries or illness.

Incidental Uses and Disclosures. There are certain incidental uses or disclosures of your information that occur while we are providing service to you or conducting our business. For example, after surgery the nurse or doctor may need to use your name to identify family members that may be waiting for you in a waiting area. Other individuals waiting in the same area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.

Other Uses and Disclosures. Other uses and disclosures of your medical information not covered above will be made only with your written permission. If you authorize us to use and disclose your information, you may revoke that authorization at any time. Such revocation will not affect any action we have taken in reliance on your authorization.

INDIVIDUAL RIGHTS

Request for Voluntary Restrictions. You have the right to request a restriction on how we use and disclose your medical information for treatment, payment and health care operations, or to certain family members or friends identified by you who are involved in your care or the payment for your care. We are not required to agree to your request, and will notify you if we are unable to agree.

Access to Medical Information. You may request to inspect and copy much of the medical information we maintain about you, with some exceptions. If you request copies, we may charge you a copying fee plus postage. If we agree to prepare a summary of your medical information, we will charge a fee to prepare the summary.

Amendment. You may request that we amend certain medical information that we keep in your records. We are not required to make all requested amendments, but will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reasons and your rights.

Accounting. You have the right to receive an accounting of certain disclosures of your medical information made by us or our business associates. The first accounting in any 12-month period is free; you may be charged a fee for each subsequent accounting you request within the same 12-month period.

Confidential Communications. You may request that we communicate with you about your medical information in a certain way or at a certain location. We must agree to your request if it is reasonable and specifies the alternate means or location.

How to Exercise These Rights. All requests to exercise these rights must be in writing. We will follow written policies to handle requests and notify you of our decision or actions and your rights. Contact Cathleen Jensen, RHIA, Privacy Officer, Community Hospital, 1301 East H Street, McCook, Nebraska 69001, 308-344-8329 for more information or to obtain request forms.

ABOUT THIS NOTICE

We are required to follow the terms of the Notice currently in effect. We reserve the right to change our practices and the terms of this Notice and to make the new practices and notice provisions effective for all medical information that we maintain. Before we make such changes effective, we will make available the revised Notice by posting it in the hospital lobby, where copies will also be available. The revised Notice will also be posted on our website at www.chmccook.org. You are entitled to receive this Notice in written form. Please contact the Medical Records Department at 308-344-2650 ext. 337 or at the address listed below to obtain a written copy.

COMPLAINTS

If you have concerns about any of our privacy practices or believe that your privacy rights have been violated, you may file a complaint with the Hospital using the contact information at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.

CONTACT INFORMATION

 EFFECTIVE DATE OF NOTICE:  April 14, 2003,  Version 1