This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
It is your right to be informed of the privacy practices of your healthcare provider and to be informed of your privacy rights with respect to your personal health information. Your personal health information is information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996.
It is required by law to maintain the privacy of your health information and to provide to you and your representative this notice of Cumberland Memorial Hospital and Extended Care Unit’s (CMH-ECU) duties and privacy practices regarding your health information. CMH-ECU is required to abide by the terms of this notice as may be amended from time to time. CMH-ECU will not use or disclose your health information without your authorization, except as described in this notice. CMH-ECU reserves the right to change the terms of this notice and to make the new notice provisions effective for all health information that it maintains. CMH-ECU also reserves the right to change the terms of this notice with respect to any applicable more limited uses and disclosures. If CMH-ECU makes a material change to this notice, CMH-ECU will provide a copy of the revised notice.
YOUR RIGHTS IN RESPECT TO YOUR HEALTH INFORMATION12
Right to Request Restrictions
You may request restrictions on certain uses and disclosures of your health information, even if the restriction affects your treatment or CMH-ECU’s payment or health care operations, however, CMH-ECU is not required to agree to your request. If you wish to make a request for restrictions, you may call 715-822-6197.
Right to Receive Confidential Communications
You have the right to request that CMH-ECU communicate with you about your health information by alternative means or at alternative locations and CMH-ECU will accommodate reasonable requests. For example, you may ask that CMH-ECU contact you at work rather than at home. If you wish to receive confidential communications, your request must be in writing and addressed to CMH-ECU.
Right to Inspect and Copy Your Health Information
You have the right to inspect and copy your health information, including billing records. This right may not apply to certain types of psychotherapy notes. A request to inspect and copy records containing your health information must be submitted in writing to CMH-ECU. If you request a copy of your health information, a reasonable fee may be charged for copying costs associated with your request.
Right to Amend Your Health Information
You have the right to request that CMH-ECU amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by CMH-ECU. A request for an amendment of records must be made in writing and include a reason to support the requested amendment to medical records at CMH-ECU. CMH-ECU may deny the request if the health information you wish to amend: 1) was not created by CMH-ECU; 2) is not part of CMH-ECU’s records; 3) is not part of the health information you are permitted to inspect and copy; or 4) in the opinion of CMH-ECU, is accurate and complete. For example, if you believe information in your medical history is incorrect, such as your date of birth, you may request that this information be amended.
Right to an Accounting
You have the right to request an accounting of disclosure of your health information made by CMH-ECU for certain purposes, which may include disclosure authorized by law. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. The accounting shall include the date of the disclosure, the name of the entity or person who received the health information, a brief description of the health information disclosed, and the reason for the disclosure. CMH-ECU will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. For example, you may request an accounting of disclosure made from your health care record in the last year to the State for disease reporting.
Right to a Paper Copy of this Notice
You have the right to a separate paper copy of this notice at any time, even if you received this notice previously.
If you have a Complaint
You have the right to express complaints to CMH-ECU or to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to CMH-ECU should be made in writing. You are encouraged to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
If you have any Questions Regarding this Notice
CMH-ECU has a designated Privacy Compliance Officer for all issues regarding patient privacy and rights under the Federal Privacy Standards.
Address all correspondence to:
Cumberland Memorial Hospital
1110 Seventh Avenue
Cumberland, WI 54829
or call 715.822.6197