Effective April 14, 2003, and revised Effective June 1st, 2022


This Notice describes how we will use and disclose your health information. The policies outlined in this Notice apply to all of your health information generated by Cameron Memorial Community Hospital and itsaffiliated entities including without limitation urgent care center, medical clinics, medical group practices, rural health centers, and retail pharmacy, and all physicians and other licensed professionals diagnosing and treating patients at such entities (hereafter CMCH), whether recorded in your medical record, invoices, payment forms, videotapes or other ways. These policies also apply to the health information gathered from other health care providers and organizations by any employee, volunteer, or independent contractor who participates in your care at a CMCH facility or practice, including information we receive and maintain in our records pursuant to CMCH’s participation in health information exchanges, accountable care organizations, or clinically integrated networks.All of the entities and persons listed will share personal health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

Uses and Disclosures of Your Health Information

  1. Uses and Disclosures that do not Require an Opportunity to Object. In some circumstances, we are permitted or required to use or disclose your health information without obtaining your prior authorization and without offering you the opportunity to object. These circumstances include:
    1. Uses or disclosures relating to treatment, payment and health care operations:
      • Treatment. We may use and/or disclose your health information to provide, or to allow others to provide, treatment to you. For example, your primary care physician may disclose your health information to another doctor for a consultation. Also, we may contact you with appointment reminders or information about treatment options or other health-related benefits and services that may be of interest to you.
      • Payment. We may use and/or disclose your health information for the purpose of allowing us, as well as other organizations, to secure payment for the health care services provided to you. For example, we may inform your health insurance company of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care services provided to you.
      • Health Care Operations. We may use and/or disclose your information for the purposes of our day-to-day operations and functions. We may also disclose your information to another covered entity (covered health care provider, health plan or health care clearinghouse) to allow it to perform certain of its day-to-day functions, but only to the extent that we both have a relationship with you. For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided at CMCH.
      • Electronic Health Record. We use an electronic health record that permits us to exchange health information electronically with other health care providers, clinics, centers, and facilities affiliated with or contracted with CMCH that are involved in your care for treatment, payment and permitted health care operations.
      • Information Exchanges, Registries and Electronic Data Sharing. We may also participate in initiatives, such as Health Information Exchanges, registries, and other electronic data sharing systems, that permit us to exchange health information electronically with payors, other health care providers, clinics, centers, and facilities, and other permitted organizations that are involved in your care for treatment, payment and permitted health care operations, even if they are not affiliated with CMCH.
      • Organized Health Care Arrangements. We may participate in accountable care organizations (“ACOs”), clinically integrated networks (“CINs”), and other organized health care arrangements with other health care providers to facilitate access to health information, improve the quality of care, and reduce the cost of care. If we do, we may use or disclose to other health care providers and covered entities also participating in these arrangements your health information for treatment, payment or health care operations. While we may participate in these arrangements, we do not assume liability for negligence, errors, omissions, or breaches of your privacy rights that are committed by other health care providers.
      • Business Associates. Certain aspects and components of our services may be performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide certain of your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
    2. When required by law, including to the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law;
    3. For public health purposes, such asrequired reporting of disease, injury, and birth and death, preventing disease, helping with product recalls, reporting adverse reactions to medications, or preventing or reducing a serious threat to anyone’s health or safety;
    4. To disclose information about victims of abuse, neglect, or domestic violence as permitted or required by law;
    5. For health oversight activities, such as audits or civil, administrative or criminal investigations;
    6. For judicial or administrative proceedings;
    7. For law enforcement purposes;
    8. To assist coroners, medical examiners or funeral directors with their official duties;
    9. To facilitate organ, eye or tissue donation;
    10. For research, subject to a special approval process unless the information is in the form of a limited data set; or we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any health information;
    11. To create de-identified health information by removing certain specified identifiers or obtaining a determination that the health information is not individually identifiable from a person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable;
    12. To create a limited data set, which is health information that excludes certain direct identifiers and may only be used or disclosed for the purposes of research, public health, or health care operations;
    13. To avert a serious threat to health or safety;
    14. For specialized governmental functions, such as military, national security, presidential protective services, criminal corrections, or public benefit purposes; and
    15. For workers’ compensation purposes, as permitted by law.
  2. Uses and Disclosures that Require an Opportunity to Object. We may also use or disclose your health information in the following circumstances. However, except in emergency situations, your incapacity, or if you are not present, we will inform you of our intended action prior to making any such disclosures and will, at that time, offer you the opportunity to object or restrict the information provided.
    1. Directories. We may maintain a directory of patients that includes your name and location within the facility, your religious designation, and information about your condition in general terms that will not communicate specific medical information about you. Except for your religion, we may disclose this information to any person who asks for you by name. We may disclose all directory information to members of the clergy.
    2. Notifications. We may disclose to your relatives or close personal friends any health information that is directly related to that person’s involvement in the provision of, or payment for, your care. We may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to organizations that are involved in those tasks during disaster situations.
  3. Uses and Disclosures that Require your Written Authorization. The following uses and disclosures of your healthinformation require your written authorization:
    1. Uses and disclosures of psychotherapy notes except:
      • To carry out the following treatment, payment, or health care operations: Use by the originator of the psychotherapynotes for treatment; use or disclosure by us for our own training programs; or use or disclosure by us to defend ourselvesin a legal action or other proceeding brought by you;
      • Uses and disclosures to the federal Secretary of the Department of Health and Human Services required by the Secretary to investigate or determine our compliance with federal privacy regulations; and
      • Uses and disclosures required by law or permitted with respect to the following: health care oversight of the originator of the psychotherapy notes; about decedents to coroners and medical examiners; or necessary to prevent or lessen a seriousand imminent threat to health or safety.
    2. Uses and disclosures for marketing purposes that involve remuneration to us from a third party, unless the communication is made in a face to face communication to you by us, or is a promotional gift of nominal value provided by us; and
    3. Disclosures that would constitute a sale of your health information.
  4. Fundraising. We may use or disclose your health information to contact you as part of our efforts to raise funds. Youhave the right to opt out of receiving such fundraising communications. All fundraising communications will include information about how you may opt out of future fundraising communications.
  5. “Part 2” Records. Except as allowed by Federal or State laws or rules, the disclosure of mental health records and any substance use disorder records subject to protection under a more stringent Federal law called “Part 2” will generallyrequire your written authorization. You may revoke your authorization at any time, in writing, unless we have taken action based on your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.

Your Rights

  1. To Request Restrictions. You have the right to request restrictions on the use and disclosure of your health informationfor treatment, payment or health care operations purposes or notification purposes. To request a restriction, submit a written request to the Designated Contact listed on the final page of this Notice. We are not required to agree to your request. However, we must agree to your request to restrict the disclosure of your health information to a health plan, if the disclosure is for payment or health care operations and it is not otherwise required by law and the health information is solely related to items or services that you (or someone on your behalf) paid us for in full. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment.
  2. To Limit Communications. You have the right to receive confidential communications about your own health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only via e-mail, or at work rather than home. To request communications via alternative means or at alternative locations, you must submit a written request to the Designated Contact listed on the final page of this Notice. All reasonable requests will be granted.
  3. To Access and Copy Health Information. You generally have the right to inspect and copy health information about you contained in clinical, billing, or other records used to make decisions about you other than psychotherapy notes and information compiled in anticipation of or for use in civil, criminal or administrative proceedings. To arrange for access to your records or to receive an electronic or paper copy of your records, you should submit a written request to CMCH HIM Release of Information, 416 E. Maumee St. Angola, IN 46703, medrecords@cameronmch.com or Fax: 260-665-7882. If you request copies, you may be charged a reasonable, cost-based fee for copying and mailing the requested information.Despite your general right to access your Protected Health Information, access may be denied in some limited circumstances. For example, access may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act applies. Access to information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if allowing you access would reasonably be likely to reveal the source of the information. The decision to deny access under these circumstances is final and not subject to review.In addition, access may be denied if (i) access to the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your access would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and a licensed health care professional determines that your access to the information would cause substantial harm to the patient or another individual. If access is denied for these reasons, you have the right to have the decision reviewed by a health care professional designated by CMCH who did not participate in the original decision. If access is ultimately denied, the reasons for that denial will be provided to you in writing.
  4. To Request Amendment. You may request that your health information be amended, if you think it is incorrect or incomplete. Requests to amend health information must be submitted in writing to CMCH HIM Department, 416 E. Maumee St. Angola, IN 46703, medrecords@cameronmch.com or Fax: 260-665-7882. Your request may be denied if the information in question: (i) was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), (ii) is not part of our records, (iii) is not the type of information that would be available to you for inspection or copying, or (iv) is accurate and complete. If your request to amend your health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates.
  5. To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your health information made during the six-year period prior to the date of your request.The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person’s address (if known), and a brief description of the information disclosed and the purpose of the disclosure. However, the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out treatment, payment or health care operations, (ii) disclosures made to you, (iii) disclosures of information maintained in our patient directory, or disclosures made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure, (vi) disclosures made pursuant to an authorization signed by you, (vii) disclosures that are part of a limited data set, (viii) disclosures that are incidental to another permissible use or disclosure, or (ix) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. To request an accounting, submit a written request to the Designated Contact listed in the final section of this Notice. We will provide one accounting a year for free, but we will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  6. To a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request, even if you agreed to receive the notice electronically. We will provide you with a paper copy promptly, if requested.

Our Duties

  1. We are required by law to maintain the privacy and security of your health information.
  2. We are required to provide you with this Notice of our legal duties and privacy practices concerning your health information. We reserve the right to change the terms of this Notice and to make those changes applicable to all health information that we maintain. Any changes to this Notice will be posted on our website, at our facility and will be available from us upon request.
  3. We are required to abide by the terms of this Notice.
  4. We are required by law to notify you if there is a breach of any of your health information which was unsecured and that compromised the privacy or security of your health information.


You can complain to us and to the federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Designated Contact listed below. The Designated Contact can also provide you with more information about the practices in this Notice upon request. No action will be taken against you for filing a complaint.

Designated Contact

For questions, please contact the Privacy Officer in the Corporate Compliance Department:

  1. In writing:
    • Attn: Privacy Officer
    • Cameron Memorial Community Hospital
    • 416 East Maumee Street
    • Angola, IN 46703
  2. By phone: 260-667-5350 or toll free: 833-703-5700

Acknowledgment of Receipt of Notice.

You will be asked to acknowledge that you received this Notice of Practice Practices during registration.


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