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. 


YOUR RIGHTS

When it comes to your health information, you have certain rights.  This section explains your rights and some of our responsibilities to help you. 

Get an electronic or paper copy of your medical record 
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you, provided your request is in writing. 

We will provide a copy of your health information, usually within 30 days of your request.  We may charge a reasonable, cost-based fee. 

In limited situations, we may deny your request.  If we do, we will tell you our reasons and explain your right to have the denial reviewed. 

Ask us to correct your medical record 
You can ask us to correct your health information about you that you think is incorrect or incomplete.  We ask that you provide your request for correction in writing. 

We may say "no" to your request, but we'll tell you why, in writing, within 60 days. 

Request confidential communications
You can ask us to contact you in a specific way.  For example, sending information to your work address or phone rather than your home address or phone or by e-mail instead of regular mail. 

We will say "yes" to all reasonable requests. 

Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations.  We are not required to agree to your request, and we may say "no" if it would affect your care. 

If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  We will say "yes" unless a law requires us to share that information. 

Get a list of those with whome we've shared information 
You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.  We ask that you provided your request in writing. 

We will include all the disclosures except for those about treatment. payment and health care operations, and certain other disclosures (suck as any you asked us to make).  We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
You may obtain a copy of this notice from our website at www.communitymh.com.  You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.  We will provided you with a paper copy promptly. 

File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting Community Memorial Hospital and Washburn Family Clinic, Privacy Officer, 220 5th Avenue West, PO Box 280, Turtle Lake, ND 58575, (701)448-2331. 

You may also contact the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 999 18th Street, Suite 417, Denver, CO 80202, or calling 1-800-368-1019 (TDD 1-800-537-7697), or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retailiate against you for filing a complaint. 



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.  

In these cases, you have both the 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 that lists your name, location in the organization, general condition and religious affiliation. 

We will make the above referenced disclosures unless you object.  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 your best interest.  We may also share your information when needed to lessen a serious and imminent threat to health or safety. 

In the case of fundraising: 
We may contact you for fundraising efforts, but you can tell us not to contact you again.  If you do not wish to be contacted for fundraising purposes, contact Administration at (701) 448-2331 or follow the instructions in the fundraising communication. 

In these cases we never share your information unless you give us written permission: 
Substance abuse treatment records
Marketing purposes in which we would receive remuneration from a third party. 
Sale of your information 



OUR USES AND DISCLOSURES

How do we typically use or share your health information? 

We typically use or share your health information in the following ways.

To treat you
We can use your health information and share it with professionals who are treating you or are involved in your care.
Example: A doctor treating you for an injury asks another doctor about your overall health condition. 

To run our organization
We can use and share your information to run our organization, improve your care, and contact you when necessary with appointment reminders or to give you information about treatment alternatives, or other health care services we offer. 
Example: We use health information about you to manage your treatment and services. 

To bill for your services 
We can use and share your health information to bill and get payment from health plans or other entities.  
Example: We give information about you to your health insuance plan so it will pay for your services. 

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research.  We have to meet many conditions in the law before we can share your information for these purposes.  For more information see: 
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. 

To help with public health and safety issues
We can share health information about you for certain situations such as: 

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications 
Reporting suspected abuse, neglect, or domestic violence 
Preventing or reducing a serious threat to anyone's health or safety

To do research 
We can use or share your information for health research 

To comply with the law 
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law. 

To respond to organ and tissue donation requests 
We can share health information about you with organ procurement organizations. 

To work with a medical examiner or funeral director 
We can share health information with a coroner, medical examiner, or funeral director when at individual dies. 

To address workers' compensation, law enforcement, and other government requests 
We can use or share health information about you: 

For workers' compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For sepcial government functions such as military, national security, and presidential protective services

To respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena. 



OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information. 

We will let you know promptly 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 coy 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.  

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. 


CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes will appy to all information we have about you.  The new notice will be available in our main reception areas, upon request, and on our web site at www.communitymh.com.