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Effective April 14, 2003


The terms of this Notice of Privacy Practices apply to Carroll County Memorial Hospital and each of its subsidiaries, affiliates, and entities managed or controlled by Carroll County Memorial Hospital, including its employees. All of the entities will share personal health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. We are required by law to maintain the privacy and security of our patients’ personal health information whether in written or electronic form and to provide patients with notice of our legal duties and privacy practices with respect to personal health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make a new Notice effective for all personal health information maintained by Carroll County Memorial Hospital. A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer, Carroll County Memorial Hospital, 1502 North Jefferson, Carrollton, MO 64633.


Authorization and Consent:

Except as outlined below, we will not use or disclose your personal health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.

Uses and Disclosures for Treatment:

With your agreement, we will make uses and disclosures of your personal health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history etc.

Uses and Disclosures for Payment:

With your agreement, we will make uses and disclosures of your personal health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations:

With your agreement, we will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and patient care.

Individuals Involved In Your Care:

With your written agreement we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with involved individuals without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. Business Associates:

Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Appointments and Services:

We may contact you to provide appointment reminders or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You may make your requests by sending your name and address to Privacy Officer, Carroll County Memorial Hospital, 1502 North Jefferson, Carrollton, MO 64633.


In limited circumstances, we may use and disclose your personal health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional review board which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.

Marketing and Sales:

Your written consent is required for use and disclosure of personal health information for all marketing and sales activities.

Data Breach:

We may use or disclose your personal health information to provide legally required notices of unauthorized access to or disclosure of your health information.

Other Uses and Disclosures:

We are permitted and/or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization for the following:

  • any purpose required by law

  • if we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence.

  • to your employer when we have provided health care to you at the request of your employer;

  • to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.

  • court or administrative ordered subpoena or discovery request;

  • to coroners and/or funeral directors consistent with law;

  • if necessary to arrange an organ or tissue donation from you or a transplant for you;

  • We may use of disclose your name, unit or room number, and religious affiliation in our facility directory. We may also disclose your religious affiliation to a member of the clergy. Information concerning your general condition or room location may be provided to callers or visitors when they ask for you by name. You may object to the release of this information. You may use the “Request to Restrict the Use or Disclosure of Personal health information” form to notify us of your objection or your objection may be made orally. If you do not want information released in the facility directory/census, we cannot tell members of the public, flower or other service persons and organizations, and even your friends and family that you are here.


    Obtain a copy of this Notice. If we provide treatment or services to you directly, you have the right to receive a written copy of this Notice.  You may also obtain a copy of this notice by on our website at

    Access to Your Personal Health Information You have the right to a copy (paper or electronic copy) and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a Patient Authorization Form from the Medical Records Department. If you request a copy of your personal health information you may be charged a nominal fee for copying and postage.

    Amendments to Your Personal Health Information:       

    You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, must be in writing, signed by you or your legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an “Amendment Request Form” from the Medical Records Department.

    Accounting for Disclosures of Your Personal Health Information:

    You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. “Accounting Request Forms” are available from the Medical Records Department. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.

    Restrictions on Use and Disclosure of Your Personal Health Information:

    You have the right to request restrictions on uses and disclosures of your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to the individual responsible for medical records.

    Workers’ Compensation:

    For patients whose medical treatment is covered under a state workers’ compensation program, please note the following: Disclosure of your personal health information (PHI) for purposes of providing treatment and obtaining payment under the state’s workers’ compensation is governed by the state workers’ compensation regulations and procedures. Therefore, we are not obligated to secure a written authorization as otherwise required by HIPAA in order to disclose your PHI for workers’ compensation purposes, nor may you restrict our use or disclosure of your PHI for workers’ compensation purposes. Written consent to use or disclose your PHI may be required pursuant to our internal policies and/or state workers’ compensation program rules in order to process your claims. Failure to provide any required written consent may result in your financial liability for medical services and supplies. Request communications of personal health information by alternative means or at an alternative location. You may request that we communicate with you other than through our normal means. For example, you may request that we communicate with you only in writing or at a different address or post office box. We will accommodate any reasonable request. To request confidential communication of personal health information about you, you must submit your request in writing to our HIPAA Privacy Contact Person at the address shown at the end of this Notice.


    If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your personal health information with respect to that item or service not be disclosed to health plan for purposes of payment or health care operations, and we will honor that request.

    Notice of Breach:

    You have the right to be notified upon a breach of any of your personal health information.

    Your Right Regarding Electronic Health Information Exchange

    Health-care providers and health plans may use and disclose your health information without your written authorization for purposes of treatment, payment and healthcare operations. Our healthcare providers are linked by an electronic medical record. When you go to an outside provider, we may be able to share and/or access your records through an electronic Health Information Exchange (HIE). Before there was an HIE, providers and health plans exchanged this information directly by hand delivery, mail, facsimile or email. This process was time consuming, expensive and not secure.

    The electronic HIE changes this process. Technology allows a provider or health plan to submit a single request through an HIE to obtain electronic records for a specific patient from other HIE participants. The provider must have sufficient personal information about you to prove they have treatment relationship with you before the HIE will allow access to your information.

    To allow authorized individuals to access your electronic health information you do not have to do anything. By reading this notice and not opting out, your information will be available through HIE.

    Opting Out: If you do not wish to share information with providers through an HIE, you must opt out. Please understand your decision to restrict information through an HIE will limit your healthcare providers’ ability to provide the most effective care for you. By submitting a request for restrictions, you accept the risks associated with that decision. Your decision to restrict access to your electronic health information through the HIE does not impact other disclosures of your health information. Providers and health plans may continue to share your information directly through other means (such as by facsimile or secure mail) without your specific written authorization. Opting out of the HIE will not prevent our providers from seeing your complete medical records.

    To opt Out Please Contact:

    Carroll County Memorial Hospital

                                                  Health Information Management

                                                  1502 N Jefferson

                                                  Carrollton, MO 64633

                                                  (660) 542-1695


    If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer, Carroll County Memorial Hospital, 1502 North Jefferson, Carrollton, MO 64633. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.


    If you have questions or need further assistance regarding this Notice, you may contact:


    Carroll County Memorial Hospital

    1502 North Jefferson

    Carrollton, MO 64633

    (660) 542-1695

    Revised:  September 2013


Carroll County Memorial Hospital posts Title VI notices on our agency’s website, in public areas of our agency, in our board room, and on our buses and/or paratransit vehicles.

Carroll County Memorial Hospital operates its programs and services without regard to race, color, or national origin, in accordance with Title VI of the Civil Rights Act of 1964.

To obtain additional information about your rights under Title VI, contact Carroll County Memorial Hospital

If you believe you have been discriminated against on the basis of race, color, or national origin by Carroll County Memorial Hospital, you may file a Title VI complaint by completing, signing, and submitting the agency’s Title VI Complaint Form.

How to file a Title VI complaint with Carroll County Memorial :

1.      To obtain a Complaint Form from Carroll County Memorial Hospital, contact Carroll County Memorial Hospital, 1502 North Jefferson, Carrollton Missouri, 64633 or click here.

2.     In addition to the complaint process at Carroll County Memorial Hospital, complaints may be filed directly with the Federal Transit Administration, Office of Civil Rights, Region VII, 901 Locust Street, Suite 404, Kansas City, MO  64106

3.     Complaints must be filed within 180 days following the date of the alleged discriminatory occurrence and should contain as much detailed information about the alleged discrimination as possible.

4.      The form must be signed and dated, and include your contact information.

If information is needed in another language, contact [660-542-1695].

Patients will not be discriminated against based on the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity, or the individual’s inability to pay; whether payment for those services would be made under Medicare, Medicaid, or CHIP. A Sliding Fee Schedule based on income and family size is available at

Machine Readable Files (MRFs)

The Transparency in Coverage Final Rules (TiC Final Rules) require group health plans and health insurance issuers to disclose on a public website detailed pricing information in machine-readable files (MRFs).