"THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY."

Effective Date: April 14, 2003

Introduction to Privacy

We are required by law to maintain the privacy of your medical information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. If we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Joint Notice Of Privacy

This Joint Notice applies to the privacy practices of the entities listed below and is limited to the purposes of compliance with the Health Insurance Portability and Accountability Act of 1996 and with the Texas Privacy Act, Senate Bill 11. These entities either operate under common ownership and/or control or are considered clinically integrated health care settings. These entities are viewed as participating in a joint arrangement for the sole purpose of using and disclosing your health information created within or received by Columbus Community Hospital Organization for treatment, payment and operations.

These Entities Include:

• Columbus Community Hospital
• Columbus Medical Clinic
• Four Oaks Medical Clinic
• Columbus Community Hospital Home Health Agency
• All Physicians and Allied Professionals who have privileges to practice at Columbus Community Hospital.

Uses and Disclosures of Medical Information

We use and disclose medical information about you for treatment, payment and health care operations. For Example:

Treatment: We may use and disclose your medical information to a physician or other health care provider in order to provide treatment to you.

Payment: We may use and disclose your medical information to obtain payment for services we provide to you. We may disclose your medical information to another health care provider or entity subject to the federal Privacy Rules so they can obtain payment.

Health Care Operations: We may use and disclose your medical information in connection with our health care operations. Health care operations include:

• Quality assessment and improvement activities;
• Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider accreditation, certification, licensing or credentialing activities;
• Medical Review;
• Legal services and auditing, including fraud and abuse detection and compliance;
• Business planning and development; and
• Business management and general administrative activities, including management activities relating to privacy, customer service, resolution of internal grievances, and creating de-identified medical information or a limited data set

We may disclose your medical information to another provider that has a relationship with you for their health care operations and payment.

On Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this Notice.

To Your Family & Friends: We may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. We may use or disclose your name, location, and general condition or death to notify, or assist in the notification of (including identifying or locating) a person involved in your care. We may also disclose your medical information to whomever you give us permission. Before we disclose your medical information to a person involved in your health care or payment for your health care, we will provide you with an opportunity to object to such uses or discloses. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.

We will also use our professional judgment and our experience with common practice to allow a person to pick up filled prescriptions, medical supplies, or other similar forms of medical information.

General Information. We may disclose your name, your location and your general medical condition to persons who ask for you by name. Further, we may disclose your religious affiliation to members of the clergy. We will include your name and location on our posted census, but will provide you with an opportunity to restrict or prohibit some or all disclosures unless emergency circumstances prevent your opportunity to object.

Disaster Relief: We may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Health Related Services: We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you.

Business Associate: We may use or disclose your medical information to a company working on behalf of the Columbus Community Hospital organization who may have access to or be given your health information in order to provide the contracted services.

Marketing: We do not use your medical information for marketing purposes. We must obtain your authorization for all marketing purposes except for face-to-face conversations about services and treatment alternatives. You may receive information through a membership program that you have joined. If you have joined a membership program and you no longer wish to receive further information, please indicate this in writing or by calling 979-732-2371.

Fundraising: We may use your demographic information and the dates of your health care to contact you for our fundraising purposes. If you do not wish to receive fundraising information, please indicate this in writing or by calling 979-732-2371.

Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

• Public Health activities including disease & vital statistics reporting, child abuse reporting, adult protective services, FDA oversight;
• Employers regarding work-related illness or injury
• Cancer Registry
• Trauma Registry
• Birth Registry
• Health Oversight Agencies;
• In response to court and administrative orders and other lawful processes;
• To law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;
• To coroners, medical examiners and funeral directors;
• To organ procurement organizations;
• To avert a serious threat to health or safety;
• In connection with certain research activities;
• To correctional institutions regarding inmates; and
• As authorized by state worker's compensation laws.

Individual Rights

You have the right to review or receive a copy of your medical information, with limited exceptions. You must make a request in writing to obtain access to your medical information. You may obtain a form to request access or a copy of your medical information from the Medical Records department located at the facility where you obtain your medical care. There may be a charge for a copy of your medical information.

Disclosure of Accounting: You have the right to receive an accounting of all uses and disclosures of your health information that was not authorized by you and that was not used, by Columbus Community Hospital organization or a business associate, for the sole purposes of treatment, payment and health care operations. You must request this accounting in writing. You may obtain a form to request an accounting of disclosures from the Medical Records department located at the facility where you obtained your medical care.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You must make this request in writing.

Confidential Communications: You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. You must make your request in writing. We must accommodate your request if it is reasonable, and specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Electronic Notice: If you receive this Notice on our web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. Please contact us using the information listed at the end of this Notice to obtain this Notice in written form.

Security of Your Information

Columbus Community Hospital organization safeguards customer information using various tools such as firewalls and passwords. We continually strive to improve these tools to meet or exceed industry standards. We also limit access to your information to protect against its unauthorized use. The only staff members of Columbus Community Hospital who can access your information are those who need it as part of their job. These safeguards help us meet both federal and state requirements to protect your personal health information.

Questions or Concerns

If you would like more information about our privacy practices or have questions or concerns about this Notice, please contact the Privacy Office at the number listed below.

If you believe your privacy rights have been violated, you may file a complaint, in writing, to the Columbus Community Hospital Privacy Office located at 110 Shult Drive, Columbus, Texas 78934 or by calling 979-732-2371

Or you may contact the U.S. Department of Health and Human Services (DHHS) 200 Independence Ave. S.W., Washington, D.C. 20201, or call Toll Free 1-877-696-6775.

To e-mail the DHHS Secretary or other Department Officials, send your message to hhsmail@os.dhhs.gov.