Cedar County Memorial Hospital Privacy Statement

Effective Date: April 14, 2003

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 the Director of Medical Records
at 417-876-2511.

WHO WILL FOLLOW THIS NOTICE?

This notice describes Cedar County Memorial Hospital (CCMH) practices and that of:

OUR PLEDGE REGARDING MEDICAL INFORMATION

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 CCMH. 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 CCMH, whether made by CCMH personnel or your personal physician. Your personal physician may have different policies or notices regarding the physician's use and disclosure of your medical information created in the physician'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:

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

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.

SPECIAL SITUATIONS

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

CHANGES TO THIS NOTICE

We reserve the light to change this notice. We reserve the right to make the revised or changed notice effective for medical information we receive in the future. We will post a copy of the current notice at each CCMH facility. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you register at or are admitted to CCMH for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with CCMH or with the Secretary of the Department of Health and Human Services. To file a complaint with CCMH, contact the Director of Medical Records. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission. in writing, at any time. If you revoke your permission, we will no longer use or disclose medical 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 permission, and that we are required to retain our records of the care that we provide to you.