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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.

This notice describes our hospital's practices and that of:
Any health care professional authorized to enter information ito your hospital chart.
All departments and units of the hospital.
Any member of a volunteer group we allow to help you while you are in the hospital.
All employees, staff and other hospital personnel.


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 hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:
Make sure that medical information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
Notify you if there is a breach of unsecured protected health information.


The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories:

For Treatment. We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other facility personnel who are involved in taking care of you at the facility. 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. Different departments of the facility also may share health information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays.
We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you're discharged from this facility.

For Payment. We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations. Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and other students for educational purposes. And we may combine health information we have with that of other facilities to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.

Fundraising. We may contact you to raise funds for the facility. We may disclose health information to a foundation related to CMCH so that the foundation may contact you to raise money for CMCH. In these cases, we would release only your name, address and phone number, age, gender, and the dates and departments of service. If you do not want us to contact you for fundraising efforts, you must notify the Privacy Official.

Business Associates. There are some services provided in our organization through contracts with third parties, or business associates, who we contract with to perform services on our behalf. Examples include a copy service we use when making copies of your health record and professional advisors we may use to help operate the facility. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we've asked them to do. To protect your health information, however, business associates are required by federal law to appropriately safeguard your information.

Hospital Directory. We may include certain limited information about you in the facility directory while you are a patient at the facility. The information may include your name, location in the facility, your general condition (e.g., good, fair) and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory please notify admission staff at time of registration or contact the Privacy Official.

Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care or to notify, or assist in the notification of (including identifying or locating), a family member, your personal representative, or another person responsible for your care of your location and general condition. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort in order to assist with the provision of this notice.

Future Communications.We may use and disclose your health information to tell you about or recommend possible treatment alternatives or health-related benefits or services that may be of interest to you, including disease-management programs, wellness programs, research projects, or other community based initiatives or activities our facility is participating in. Additionally, we may use and disclose your health information to provide appointment reminders. We may communicate to you via newsletters, mail outs or other means, including telephone, and may leave messages on your answering machine/voice mail. If you do not wish us to contact you for these purposes or by these means, you must notify us in writing and state the activities from which you wish to be excluded.

Organized Health Care Arrangement.This facility and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

Health Information Exchange/Regional Health Information Organization.Federal and state laws permit us to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share your health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of your health records; decreasing the time needed to access your information; aggregating and comparing your information for quality improvement purposes; and such other purposes as may be permitted by law.

As Required by Law.We may disclose information when required to do so by law.

As permitted by law, we may also disclose health information to the following types of entities, including but not limited to:
• Food and Drug Administration
• Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
• Correctional Institutions
• Worker's Compensation Agents
• Organ and Tissue Donation Organizations
• Military Command Authorities

Law Enforcement. We may disclose health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.

For Judicial or Administrative Proceedings We may disclose protected health information as permitted by law in connection with judicial or administrative proceedings, such as in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to obtain an order protecting the information requested or to tell you about the request and give you an opportunity to object to the disclosure.

Authorization Required. We must obtain your written authorization for most uses and disclosures of psychotherapy notes, for marketing purposes, or to sell your protected health information.

State-Specific Requirements. Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.


Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:

Right to Inspect and Copy. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care and to direct us to transmit such information directly to an entity or person clearly, conspicuously, and specifically designated by you. Usually, this includes medical and billing records, but does not include psychotherapy notes. If we maintain health information about you in electronic format, you also have the right to obtain a copy of such information in a readily producible electronic format. If you request a copy of the health information, we may charge a fee for the cost of copying, mailing and 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 health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review your request and the denial. The person conducting the review will not be the person who denied 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. You have the right to request an amendment for as long as the information is kept by or for the facility. Any request for an amendment must be sent in writing to the Privacy Official. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or health care operations where an authorization was not required. The first list you request within a 12-onth period of time will be free. We may charge you for the cost of providing additional lists.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. Any request for a restriction must be sent in writing to the Privacy Official. For any services for which you paid out-of-pocket in full, we will honor your request to not disclose health information about those services to your health plan, provided that such disclosure is not necessary for your treatment. In all other circumstances, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

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 may ask that we contact you at work instead of your home. The facility will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.


We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and include the effective date. In addition, each time you register at or are admitted to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.


If you believe your privacy rights have been violated, you may file a complaint with the facility by sending your complaint to CMCH, Attn: Privacy Official, 416 E. Maumee St., Angola, IN 46703. You may also file a complaint 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.


Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.


If you have questions or need further assistance regarding this Notice, you may contact Cameron Hospital's Privacy Officer, Christina Krueckeberg, at 260-665-2141 extension 5350.


This Important Privacy Notice is effective September 23, 2013.