Notice of Privacy Practices
Community Memorial Hospital & C&NC
512 Skyline Boulevard, Cloquet, MN 55720

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
NOTICE OF PRIVACY PRACTICES

 THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.
  • Your confidential healthcare information may be released to other healthcare professionals within the hospital for the purpose of providing you with quality healthcare.
     
  • Your confidential healthcare information may be released to your insurance provider for the purpose of the hospital receiving payment for providing you with needed healthcare services.
     
  • Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.
     
  • Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.
     
  • Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).
     
  • Your confidential healthcare information may be released for worker’s compensation or similar programs.
     
  • Your confidential healthcare information may not be released for any other purposes than that which is identified in this notice.
     
  • Your confidential healthcare information may be released for all other reasons not listed above, only after receiving written authorization from you. You may revoke your permission to release confidential healthcare information at any time.
     
  • You may be contacted by the hospital to remind you of any appointments, healthcare treatment options or other helath services that may be of interest to you.
     
  • The designated record set is defined as the medical record and billing record.
     
  • Fundraising:

    You may be contacted by this facility for the purposes of raising funds to support facility operations. If you do not want the facility to contact you for fundraising efforts, you must notify the facility at (218) 879-4641
     
  • Right to Request Restrictions:

    You have the right to restrict the use of your confidential healthcare information. However, the hospital may chose to refuse your restriction if it is in conflict of providing you with quality healthcare or in the event of an emergency situation.

    To request restrictions, you must make your request in writing to:
    Health Information Services Director/Privacy Officer
    Community Memorial Hospital
    512 Skyline Boulevard
    Cloquet, MN 55720

    In your request, you must tell us:
    1. What information you want to limit;
    2. Whether you want to limit our use, disclosure or both: and
    3. To whom you want the limits to apply
     
  • 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 can ask that we only contact you at work or by mail)

    To request confidential communications, you must make your request in writing to:
    Health Information Services Director/ Privacy Officer
    Community Memorial Hospital
    512 Skyline Boulevard
    Cloquet, MN 55720

    We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
     
  • Right to Inspect and Copy:

    You have the right to review, inspect, and photocopy any/all portions of your healthcare information. This includes medical and billing records.
    To inspect or request photocopies of your healthcare information you must submit your request in writing to:
    Health Information Department
    Community Memorial Hospital
    512 Skyline Boulevard
    Cloquet, MN 55720

    If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or 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 medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the hospital 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:

    You have the right to make changes to your healthcare information. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.

    To request an amendment, your request must be made in writing and submitted to the following address. In addition, you must provide a reason that supports your request.

    Health Information Services Director/ Privacy Officer
    Community Memorial Hospital
    512 Skyline Boulevard
    Cloquet, MN 55720

    We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
     
    • Was not created by us;
    • Is not part of the medical information kept by or for the facility
    • Is not part of the information which you would be permitted to inspect and
      copy; or
    • Is accurate and complete
       
  • Right for an Accounting of Disclosures:

    You have the right to know who has accessed your confidential healthcare information and for what purpose.

    To request an account of disclosures, you must submit your request in writing to:

    Health Information Services Director/ Privacy Officer
    Community Memorial Hospital
    512 Skyline Boulevard
    Cloquet, MN 55720

    Your request must state a time period which may not be longer than six (6) years and may not include dates before April 14, 2003.
     
  • Right to a Paper Copy of this Notice:

    You have the right to possess a copy of this Privacy Notice upon request. You may ask us to give you a copy of this at any time. This copy can be in the form of an electronic transmission or on paper.

    To obtain a copy of this notice, please contact the Health Information Services Department at (218) 878-7023

    We reserve the right to change this notice. We will post a current copy of the notice in the facility. The notice will contain on the first page, in the top right hand corner, the last revision. In addition, each time you register at or are admitted to the facility for treatment or services, we will offer you a copy of the current notice in effect.
     
  • This facility is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information.
     
  • Complaints You have the right to complain to the facility or with the Secretary of the Department of Health and Human Services if you believe your right to privacy have been violated. To file a complaint with the facility, contact the Health Information Services Director/ Privacy Officer at (218) 878-7023. All complaints must be submitted in writing.

    All complaints will be investigated. You will not be penalized for filing a complaint.
     
  • For further information about this Privacy Notice, please contact:
    Hospital CEO/ Administrator
    (218) 879-4641

    This notice is effective as of April 14, 2003