This notice applies to all entities of Community Mercy Health Partners.

Effective: January 1, 2008

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.

If you have any questions about this notice, please contact Sheryl Head, Corporate Responsibility/HIPAA Officer, at (937) 328-9300 or e-mail: privacyofficer@health-partners.org

A copy of this Notice of Privacy Practices is available on-line by accessing our website: www.community-mercy.org or by calling any of the facilities listed below and requesting a copy.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information means health information, including demographic information, collected from you and created or received by your health care provider (hospital, nursing home physician, etc), health plan, your employer or a health care clearinghouse. This protected health information relates to your past, present or future physical or mental health or condition and identifies you, or there is a reasonable basis to believe the information may identify you.

This Notice of Privacy Practices applies to all of the services offered, departments operated, and facilities governed by Community Mercy Health Partners (CMHP hereafter). Those services and facilities are listed at the end of this Notice
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Medical Staff are subject to this Notice (only while treating you at any of our facilities); our Medical Staff might have different policies or notices if they treat you outside of our facilities.

Physicians who render professional services to you in facilities governed by CMHP are independent practitioners and are not employees or agents of the facility. CMHP is not responsible for the acts or omissions of physicians that are not directed or controlled by CMHP. This notice does not apply to records maintained by, or used on disclosures of PHI by independent physicians who may treat you at a CMHP facility.

We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice, at any time. The new Notice will be effective for all protected health information that we may hold at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the facilities listed at the end of this document and requesting that a revised copy be sent to you in the mail, viewing or printing a copy from the website or by asking for one at the time of your next appointment.

This Notice does not create a contractual relationship and should not be viewed as one.

1. Uses and Disclosures of Protected Health Information Based Upon your Written Consent.

CMHP will ask you to sign an acknowledgement form. Once you have acknowledged to the use and disclosure of your protected health information for treatment, payment and health care operations by signing the acknowledgement form, CMHP will use or disclose protected health information for the following purposes:

Treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. For example, we could disclose your protected health information, as necessary, to physicians that are contracted with CMHP to assist in providing care to you. We may also disclose protected health information to other physicians or health care providers who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Your protected health information may be provided to a specialist or laboratory that, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment.

Payment. Your protected health information may be used to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for your health care services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a medical procedure or a hospital stay may require that your protected health information be disclosed to the health plan to obtain approval for the procedure or hospital admission.

Health Care Operations. We may use or disclose your protected health information in order to support the business activities of CMHP. These activities include, but are not limited to, the day-to-day running of CMHP, quality assessments, employee reviews, training of medical students, training of health care workers (e.g. nursing students, radiology technicians, medical technicians, etc.) licensing, consumer health education and fundraising, calling for reminder appointments, conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students who see patients at our facility. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room after coming to the facility for an appointment. We may contact you to remind you of your appointment but will not leave treatment or procedure information on an answering machine.

We may share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the organization. Whenever an arrangement between our organization and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. CMHP may disclose your PHI when required by law to do so in instances of communicable disease, abuse or neglect.

We may use or disclose your protected health information to provide you with information about treatment, alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other consumer health information activities. For example, your name and address may be used to send you a newsletter about our facilities and the services we offer. We may also send you information about products and services that we believe may be beneficial. You may contact our HIPAA Officer in writing to request not to receive these materials.

We may use or disclose your demographic information (name, address, date of birth, etc.) and the dates that you received treatment, as necessary, in order to contact you for fundraising activities supported by our facility. If you do not want to receive these materials, please contact our HIPAA Officer in writing and request that these fundraising materials not be sent to you.

In the event that Community Mercy Health Partners is sold or merged with another organization, your protected health information/medical record will become the property of the new owner.

2. Uses and Disclosures of Protected Health Information Based Upon your Written Authorization.

Other uses and disclosures of your protected health information may be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing to the HIPAA Officer, except to the extent that your facility or provider has taken an action in reliance on the use or disclosure indicated in the authorization.

3. Other Permitted and Required Uses and Disclosures that may be made with your Consent, Authorization, or Opportunity to Object.

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then CMHP may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Facility Directories: Unless you object in writing, are not present or able to object, we may use and disclose in our facility directory your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will be disclosed unless otherwise specified. Only members of the clergy will be told your religious affiliation by congregation membership only.
Others Involved in Your Healthcare: Unless you object in writing, are not present or able to object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, CMHP shall try to obtain your acknowledgement as soon as reasonably practicable after the delivery of treatment. If CMHP is required by law to treat you and has attempted to obtain your acknowledgement but is unable to obtain your acknowledgement, we may still use or disclose your protected health information to treat you.

4. Other Permitted and Required Uses and Disclosures that may be made without your Consent, Authorization, or Opportunity to Object.

We may use or disclose protected health information in these following situations without your consent or authorization. These situations include:

Required by Law: We may use and disclose your protected health information if the use or disclosure is required by law. The use or disclosure will be made in compliance with the law.

Public Health: We may disclose your protected health information to public health authorities for purposes related to controlling disease, injury or disability. This includes:

• Communicable Diseases: We may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

• Abuse or Neglect: We may disclose your protected health information to report child or elder abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence.

• Health Oversight Audits or Inspections: We may disclose your protected health information to state or federal inspectors in their capacity of performing audits of the operations and quality of care delivery of CMHP.

Food and Drug Administration: We may disclose your protected health information to report adverse events and product defects or problems; to enable product recalls; or to make repairs or replacements.

Legal Proceedings: We may disclose your protected health information in the course of any legal, judicial or administrative proceeding.

Law Enforcement: We may also disclose protected health information to a law enforcement official for purposes such as legal proceedings; request for identification and location of a suspect, fugitive, material witness or missing person; pertaining to victims of a crime; suspicion that death has occurred as a result of criminal conduct; that a crime has occurred on the premises of the facility; and medical emergency and it is likely that a crime has occurred. We may disclose protected health information, if we believe that the use of disclosure is necessary to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.

Coroners and Funeral Directors: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties. We may also disclose protected health information to a funeral director, in order to permit the funeral director to carry out his/her duties. We may disclose such information in reasonable anticipation of death.

Organ Donation: We may disclose protected health information to organizations involved in organ and tissue donation and transplant.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and establish protocols to insure the privacy of your protected health information.

Military Activity and National Security: We may use or disclose your protected health information to individuals about armed forces personnel for activities deemed necessary by appropriate military command authorities, or for the purpose of determination by the Department of Veterans Affairs of your eligibility for benefits. We may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with Workers’ Compensation laws and other similar legally-established programs.

Correctional Facilities: If you are an inmate, or are in lawful custody of a law enforcement official, we may use or disclose your protected health information if the correctional institution or law enforcement official represents that such protected health information is necessary for: (i) the provision of health care to you, (ii) the health and safety or you or other inmates, (iii) the health and safety of the officer or other employees at the correctional institution or who are involved in transporting inmates, (iv) law enforcement on the premises of the correctional institution, or (v) the administration and maintenance of the safety, security and good order of the correctional institution.

5. Your Health Information Rights.

You have the Right to Inspect and Copy your Protected Health Information: This means you may inspect and obtain a copy of protected health information about you for as long as we maintain the protected health information. Charges may be assessed for the copying of records where allowed by law. Contact the Health Information Management Department in the facility listed below where you received services to make arrangements for inspection or copying of records.

Under federal law, there may be instances where you may not inspect or copy your protected health information. Depending on the circumstances, a decision to deny access may be reviewable. Please contact our Corporate Responsibility/HIPAA Officer at (937) 328-9300 or privacyofficer@health-partners.org, if you have any questions about access to your protected health information.

You have the Right to Request a Restriction of your Protected Health Information: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members, friends or others who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

CMHP is not required to agree to a restriction that you may request. If CMHP believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If CMHP does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with CMHP.

You have the Right to Request to Receive Confidential Communications from us by Alternative means or at an Alternative Location: We will accommodate reasonable requests. Please make this request in writing to our Corporate Responsibility/HIPAA Officer at Community Mercy Health Partners, 2615 E. High Street, Springfield, Oh, 45505, (937) 328-9300 or privacyofficer@health-partners.org

You may have the right to have your physician amend your protected health information: This means you may request to have your protected health information changed for as long as we maintain this information. This request must be submitted in writing to the Privacy Officer. In certain cases, we may deny your request to have your protected health information changed. If we deny your request for a change, you have the right to disagree with us. Please contact our Corporate Responsibility/HIPAA Officer at (937) 328-9300 or privacyofficer@health-partners.org if you have questions about making amendments to your protected health information and how you can disagree with our decision.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information: This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, family members or friends involved in your care or for notification purposes. It also excludes disclosure of medical records we have made using an authorization signed by you or your legal representative. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us: This Notice is available on our web site or in paper form. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Corporate Responsibility/HIPAA Officer at (937) 328-9300 or privacyofficer@health-partners.org

6. Complaints

You may complain to us by contacting our Corporate Responsibility/HIPAA Officer, Sheryl Head at (937) 328-9300 or privacyofficer@health-partners.org for further information about the complaint process. You may also complain to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.

Listing of Facilities and Services
Springfield Regional Medical Center

High Street Campus
Fountain Avenue Campus
Acute Rehabilitation Unit
Community Mercy Home Medical Equipment
Community Mercy Hospice
Community Mercy Outpatient Rehabilitation
Community Mercy REACH
Excel Sports Medicine
Mercy Lifeline
Keifer Mercy Health Center
Mercy Parent-Infant Center
Mercy Well Child Pediatrics
Springfield Regional Imaging Center
Springfield Regional School of Nursing

Community Mercy Occupational Health and Medicine
CH Health Care Center

Community Mercy Urgent Care

Other Regional Services:

Administration
Corporate Responsibility
Community Relations
Education
Human Resources
Legal Services
Mission Services
Risk Services

DOC. ID. HIPAA (Rev. 12/2007)