This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice also describes how Citrus Memorial Health Foundation, Inc.(CMH) may use other information about you. Please review it carefully. Who We Are: This notice describes the privacy practices of Citrus Memorial Health Foundation, which includes, but is not limited to, Citrus Memorial Hospital, Citrus Primary Care, CMH Home Health Agency, CMH Allen Ridge Family Care, Allen Ridge Diagnostic Imaging Center and its' employees. Our Privacy Obligations: Certain laws require CMH to maintain the privacy of medical and health information about you ("Protected Health Information") and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. "Protected health information" is information about you, 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. When we use or disclose Protected Health Information (PHI), we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

Treatment: We may use and disclose PHI to provide treatment and other services to you - for example, to diagnose and treat your injury or illness. We may share PHI with members of our medical staff who are actively involved in providing care to you, as well as with physicians who are caring for you outside of our medical staff when directed to do so. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. We may contact you to provide appointment reminders for upcoming services. We may also use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordinating or managing your health care with an appropriate third party that needs to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. In addition, we may disclose your protected health information from time-to-time to another health care provider (e.g., a laboratory) who becomes involved in your care by providing assistance with your health care diagnosis or treatment. We may also disclose your protected health information if requested to do so by a health care provider caring for you in a medical emergency (such as when a hospital emergency department calls requesting information after you have been in an accident).

Payment: We may use and disclose Protected Health Information to obtain payment for services that we provide to you at a CMH facility. For example, we may use or disclose Protected Health Information to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care ("Your Payer"), and to verify that Your Payer will pay for health care. We may also share PHI as necessary with our medical staff members and health care facilities that are involved in your care in order to assist them in obtaining payment for services.

Health Care Operations: At CMH, we may use and disclose Protected Health Information for our health care operations, which includes internal administration, planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. This includes our business planning, customer service, and quality assessment/improvement activities. We may also disclose Protected Health Information in order to assist our medical staff or other health care facilities to maintain health care operations or for the purpose of health care fraud and abuse detection or compliance. For example, we may share PHI with a member of our medical staff if they are requesting it to use in the process of maintaining compliance with Medicare regulations.

To remind you that you have an appointment for medical care; To assess your satisfaction with our services; To tell you about possible treatment alternatives; To tell you about health-related benefits or services; To contact you as part of fund-raising efforts; To inform Funeral Directors consistent with applicable law; For population based activities relating to improving health or reducing health care costs; and For conducting training programs or reviewing competence of health care professionals. programs, or other community based initiatives or activities our facility is participating in. To communicate findings gathered at one of our healthcare screenings (such as a blood pressure screening) to health care providers for follow-up treatment. Business Associates: We may disclose PHI to persons or businesses which use your PHI to perform work on behalf of our organization or to bill for their services. Such business associates include companies which perform diagnostic services for CMH and such voluntary accrediting organizations as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Use or Disclosure for Directory of Individuals in a CMH Facility: Unless you disagree or object, we may include your name, location in a CMH facility, general health condition and religious affiliation in a patient directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to appropriate members of the clergy.

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.

Marketing Communications: We will not use or disclose Protected Health Information for marketing communications without your specific authorization except when we identify health-related services and products that may be beneficial to your health in face-to-face interaction with you.

Public Health Activities: We may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability, as required by law and public health concerns; (2) to report suspected abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; and (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk to contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence: We may disclose Protected Health Information without Your Consent or Authorization to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

Health Oversight Activities: We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid, as well as other duly authorized state or federal agencies carrying out health oversight activities.

Judicial and Administrative Proceedings: We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials: We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

Health or Safety: We may disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.

Specialized Government Functions: We may disclose Protected Health Information to units of the government with special functions, such as the U.S. military, Food and Drug Administration or the U.S. Department of State.

Decedents: We may disclose Protected Health Information to a coroner or medical examiner as authorized by law. We also will disclose information on decedents to funeral homes which is necessary for the preparation of a death certificate. We may also disclose information to organ/tissue donation organizations.

Organ and Tissue Procurement: We may disclose Protected Health Information to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.

Research: We may use or disclose Protected Health Information without your consent or authorization if our Institutional Review Board approves a waiver of authorization for disclosure.

Workers' Compensation: We may disclose Protected Health Information as necessary to comply with workers' compensation laws.

Other Uses and Disclosures of Your PHI: Federal regulations require us to obtain your written authorization to use or disclose your Protected Health Information for purposes not indicated in the preceding lists of allowable uses and disclosures. You may revoke this authorization at any time, in writing, by delivering your cancellation in writing to the Citrus Memorial Hospital Medical Record Department. However, the cancellation of authorization will not apply to any uses and disclosures which have already taken place in reliance on the use or disclosure indicated in the authorization.

If you desire further information about your privacy rights, you may contact our Privacy Officer as follows.

Privacy Officer, Citrus Memorial Hospital, 502 W. Highland Boulevard, Inverness, FL 34452 (352) 344-6547

If you are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to Protected Health Information, you may contact the CMH Risk Manager as follows:

Risk Manager, Citrus Memorial Hospital, 502 W. Highland Boulevard, Inverness, FL 34452 (352) 344-6589

You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Risk Management Department will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with the Director or us.

Requesting Additional Restrictions: You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment, and health care operations, (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.

Request Confidential Communications: You have the right to request that we communicate with you in a certain way or at a certain location. For example, you can ask that we contact you at your workplace or by U.S. Mail. We will only grant requests for confidential communications at alternative locations and/or via alternative means if the individual's request includes a mailing address where the individual will receive bills for services rendered by CMH and related correspondence regarding payment for services. Please realize, 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 trying to contact you by other means or at another location.

Inspect and Copy Your Health Information: You may request access to your medical record file, as well as your payment, claims adjudication, case, medical management records, and your billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you request a copy or copies of your record, you will be charged a cost-based fee for each copy.

Amend Your Records: You have the right to request that we amend Protected Health Information maintained in your medical record file, payment, claims adjudication, case, medical management records, or billing records. We will comply with your request as long as the information is kept for or by CMH, unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

Receive Paper Copy of This Notice: Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is an accounting of certain PHI disclosures we may have made outside of those for healthcare treatment, payment or operations. To request this list or accounting of disclosures, you must submit your request in writing to Medical Records Department, Citrus Memorial Hospital, 502 W. Highland Boulevard, Inverness, FL 34452. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Effective Date of This Notice: This Notice describes the privacy policy of CMH that will become effective on or before April 14, 2003, the date that federal law specifies for these protections of Protected Health Information. CMH reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI it maintains. If the Notice of Privacy Practices is modified, the new version will be made available to the public in registration areas at CMH, as well as be posted on the CMH Internet website. Prior to the effective date, CMH will continue to protect your Protected Health Information as required by other applicable

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