COOSA VALLEY MEDICAL CENTER
NOTICE OF PRIVACY PRACTICES

Effective 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.

THE PRIVACY OF YOUR MEDICAL INFORMATION IS
IMPORTANT TO US.

(printable version)

This notice gives you information required by law about the duties and privacy practices of COOSA VALLEY
MEDICAL CENTER to protect the privacy of your medical information.

We use the term “medical information” in this notice to mean your protected health information, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services and other information related to your health care that we maintain about you.

Our Contact Office. To request additional copies of this notice or to receive more information about our privacy practices or your rights, please contact us at the following Contact Office: 256-401-4616.

We are required by law to:

• Maintain the confidentiality of your medical information in accordance with applicable federal and/or state law;
  
  
• Comply with the terms of this notice until it is replaced with a new notice; and
  
  
• Give you this notice of our legal duties and privacy practices with respect to medical information we
  maintain about you.

We reserve the right to change the terms of this notice at any time. We also reserve the right to make the changes apply to your medical information we already have. Before we make a material change to this notice, we will promptly post a new notice in a clear and prominent area at our facility and on our website. You can also request a copy of the new notice from any of our registration staff at our facility.

How May We Use or Disclose Your Medical Information?

We may use and disclose your medical information without your authorization for treatment, payment, and health care operations as explained below:

For Treatment: We may use and disclose your medical information to the physicians, nurses, and other health care personnel located at each of our facilities who provide, coordinate or manage your health care and any related services. For example, our doctors and nurses may use and disclose your medical information with each other to provide treatment to you. We may also disclose your medical information to another health care provider who is not located at our facility, at his request, for your treatment by him. For example, your medical information may be provided to a doctor to whom you have been referred so that he may diagnose or treat you.

For Payment: We may use and disclose your medical information in order to bill and collect payment for the treatment and services provided to you. For instance, we may provide portions of your medical information to your health insurance plan to get paid for the health care services we provided to you. We may also disclose your medical information to your health insurance plan to permit it to make a determination of eligibility or coverage for insurance benefits, to review the services we provided to you for medical necessity, and to perform utilization review activities. We may also disclose medical information about you to the responsible party of your account. If you are listed as a dependent on another person’s insurance policy, financial information regarding medical care provided may be mailed to that responsible party. In addition, if you do not timely pay us for the health care services we provided to you, we may also disclose limited medical information to a collection agency. We may also disclose your medical information to other health care providers, health plans or health care clearinghouses for their payment activities. For example, we may provide your medical information to an ambulance/transportation company that provided services to you.

For Health Care Operations: We may use and disclose your medical information in order to support our business activities, such as quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for our other business activities. For example, we may use your medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose your medical information to medical school students who see patients at our facility. In addition, we may use and disclose your medical information to other health care providers, health plans or health care clearinghouses for their limited health care operations, such as quality assessment activities, licensing and other health care compliance activities.

Organized Health Care Arrangement: Coosa Valley Medical Center has a medical staff, which includes physicians and other professionals who are not employees of the hospital. Members of the medical staff of Coosa Valley are not part of the single affiliated covered entity, unless they are employed by the hospital or one of the companies or other facilities that is part of the single affiliated covered entity. Instead they are participants in an organized health care arrangement with that hospital. This permits our hospital and its medical staff to share protected health information for purposes of treatment, payment and/or health care operations (described above) relating to such organized health care arrangement.

Business Associates: We may disclose your medical information to our business associates that assist us in our delivery of health care and related services, such as billing companies, lawyers, accountants and others. Before we disclose your medical information to our business associates, we will have a written contract with each of them that will require each of them to agree to maintain the privacy of your medical information.

Below are other reasons we may use and disclose your medical information without your consent or authorization:

Uses and Disclosures Required by Law. We may use or disclose your medical information as required by law, but must limit such use or disclosure to relevant information and otherwise comply with applicable legal requirements. We must also disclose your medical information to the Secretary of Health and Human Services to determine our compliance with federal privacy laws.

Public Health Activities. We may use or disclose your medical information to public health authorities authorized to receive or collect information for public health purposes, such as for preventing or controlling disease and certain regulatory activities of the Food and Drug Administration.

Abuse, Neglect, or Domestic Violence. We may use or disclose your medical information in some instances if we reasonably believe that you are a victim of abuse, neglect, or domestic violence.

Health Oversight Activities. We may use or disclose your medical information to a health oversight agency for health oversight activities authorized by law, including, for example, inspections and licensure of health care facilities.

Judicial and Administrative Proceedings. We may use or disclose your medical information under certain conditions to comply with legal proceedings, such as a subpoena or order by a court or administrative tribunal.

Law Enforcement Purposes. We may use or disclose your medical information for law enforcement purposes to law enforcement officials, such as for identification of suspects or where a crime has been committed on our premises.

Decedents. We may use or disclose medical information about decedents to coroners, medical examiners, and funeral directors.

Organ, Eye, Tissue Donation. We may use or disclose your medical information to notify organ procurement organizations to assist them in organ, eye or tissue donation and transplants.

Research. In limited circumstances, we may use and disclose your medical information to conduct medical research.

Serious Safety Threat. We may use or disclose your medical information where we believe it is necessary to prevent or lessen a serious threat to the safety of a person or the public.

Special Government Functions. We may use or disclose your health information under some circumstances for specialized government functions, including those related to the armed forces, national security, and intelligence.

Workers’ Compensation. We may use or disclose your medical information as authorized by and to the extent necessary to comply with laws related to workers’ compensation and similar programs.

Scheduling Appointments, Appointment Reminders and Health Related Benefits or Services. We may use and disclose your medical information to schedule appointments, give you appointment reminders, and give you information about treatment alternatives or other health care related services or benefits we offer.

Fundraising. We may use and disclose your demographic information and the dates that you received treatment, as necessary, to contact you for fundraising activities supported by us.

To Your Personal Representatives. We may disclose your medical information to your personal representatives that are appointed by you or authorized by applicable law.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. We may release such information for purposes that include (1) providing you with health care; (2) protecting your health and safety or the health and safety of others; or (3) protecting the safety and security of the correctional institution.

Potential Impact of State Law. In some situations, the federal privacy laws do not preempt (or take precedence over) state privacy laws that give you greater privacy protections. As a result, the privacy laws of a particular state might impose a privacy standard under which we will be required to operate. For example, Alabama law may provide greater privacy protections to medical information related to artificial insemination records, sexually-transmitted diseases, and certain mental health records.

Uses and Disclosures for which You Have An Opportunity to Agree or Object:

Facilities/Patient Directories. We may include your name, location in our facility, general condition, and religious affiliation in our patient directory at your location for use by clergy and visitors who ask for you by name unless you object in whole or in part. The opportunity for you to agree or object may be given retroactively in emergency situations.

Individuals Involved in Your Care. We may disclose your medical information to a family member, friend or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity for you to agree or object may be given retroactively in emergency situations.

Your Authorization Is Needed for Other Uses and Disclosures. We will not use or disclose your medical information for any other purpose unless you give us written authorization to do so. If you give us written authorization to use or disclose your medical information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at any time. Your revocation will be effective for all your medical information that we maintain, unless we have taken action in reliance on your authorization.

What Rights Do You Have Regarding Your Medical Information?

The Right to Request Additional Restrictions on Uses and Disclosures of Your Medical Information. You have the right to ask that we put additional restrictions on how we use and disclose your medical information. We do not have to agree to your request.

The Right to Inspect and Copy Your Medical Information. You have the right to inspect and copy your medical information that we may use to make decisions about you. In limited circumstances, we do not have to agree to your request.

The Right to Amend or Correct. If you feel that your medical information is incorrect or incomplete, you have the right to ask us to correct or amend the information. We will require that you submit the request in writing and explain your reasons for asking for an amendment. In some cases, we do not have to agree to your request.

The Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters by a different means or at a different location than what we are currently doing. In limited circumstances, we do not have to agree to your request.

Paper Copy of this Notice. You have the right to request and receive a paper copy of this notice if you received it by email or on the Internet.

The Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we and our business associates made for certain purposes for the last six (6) years (except for disclosures made before April 14, 2003). If you want to exercise any of these rights described in this notice, please contact our Contact Office. We will give you the necessary information and forms for you to complete and return to us. In some cases, we may charge you a nominal fee to carry out your request.

How to Complain About Our Privacy Practices. If you think we may have violated your privacy rights, you may file a complaint with our Contact Office. You also may send a written complaint to the Secretary of the Department of Health and Human Services. We will take no retaliatory action against you if you file a complaint about our privacy practices.

CV-04-5024 REV. 10/11/04