If you have any questions about this notice, please contact the CRMC Privacy Officer by dialing the main hospital number (940-937-6371) during normal business hours.

Each time you visit CRMC, a record of your visit is made. This record may contain your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by CRMC, whether made by hospital personnel, agents of CRMC, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.

We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.

The following categories describe examples of the way we use and disclose health information:

For Treatment: We may use health information about you to provide you with treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical or nursing students, other hospital personnel or other healthcare providers who are involved in taking care of you at CRMC. For example: a doctor treating you for a broken leg may need to know if you have another medical condition that may affect the healing process. Different departments of CRMC also may share health information about you in order to coordinate the different things you may need such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you’re discharged from this hospital.

For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine if it is a covered benefit.

For Health Care Operations: Members of the medical staff and/or performance improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The result will then be used to continually improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and other students for educational purposes. And we may combine health information we have with that of other hospitals to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.

We may also use and disclose health information:

When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department and radiology and certain laboratory tests. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: We may include certain limited information about you in the hospital directory while you are a patient at CRMC. The information may include your name, location in CRMC, you general condition (e.g., good, fair), and your religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory and/or the clergy directory, please notify the admissions staff.

Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Future Communications: We may communicate to you via newsletters, direct mail, or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our facility is participating in.

Organized Health Care Arrangement: CRMC, its medical staff members, and other health care providers who participate in your care at CRMC have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment, and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time of your visit in their office.

As Required by Law: We may also use and disclose health information for the following types of entities, including, but not limited to:

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law in response to a valid subpoena.

State-Specific Requirements: Texas has some reporting requirements including population-based activities relating to improving health or reducing health care costs. Some Texas privacy laws apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.

Although your health record itself is the physical property of CRMC, the protected health information in the record belongs to you. You have the right to:

Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. We may be allowed to charge you for the cost of making the copy according to Texas Department of Health guidelines. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by CRMC 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.

Amend: If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for CRMC. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of disclosures. This list of certain disclosures we make of your health information for purposes other than treatment, payment, or health care operations where an authorization was not required.

Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

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 may ask that we contact you at work instead of your home. The facility will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. You may print or view a copy of the notice by the clicking the Privacy link on CRMC’s website at www.childresshospital.com

To exercise your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in CRMC and include the effective date. In addition, each time you register at or are admitted to CRMC for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

You will not be penalized for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with either the CRMC Privacy Officer or you may call the Privacy Officer and request a complaint form. CRMC requests that you attempt to resolve your complaint with the Privacy Officer via these complaint procedures since CRMC is in the best position to respond to your complaint. However, you may also file a complaint with the Office of Civil Rights ("OCR"). Contact information to follow:

Childress Regional Medical Center
P.O. Box 1030
Childress, TX 79201
(940) 937-6371

Medical Privacy Complaint Division
Attn: Privacy Officer Office of Civil Rights
United States Department of Health and Human Services
HHH Building
200 Independence Avenue, S.W., Room 509F
Washington, D.C. 20201
Voice Hotline Number (800) 368-1019
Internet Address www.hhs.gov/ocr

Other uses and disclosures of your protected health information, not covered by this notice or the law, will be made only with your written permission. If you provide us permission to use or disclose health 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 health 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 provided to you.

Typed on new letterhead on 02-16-2004.