Cookeville Medical Clinic/Center will disclose your health information for public health reporting required by federal or state law.  These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if Cookeville Medical Clinic/Center believe a patient has been the victim of abuse, neglect or domestic violence.  Cookeville Medical Clinic/Center will only make this disclosure if you agree or when required or authorized by law.

Cookeville Medical Clinic/Center will disclose your health information as required by law to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, Cookeville Medical Clinic/Center will disclose your health information when properly ordered to do so by a court.

Law Enforcement

Cookeville Medical Clinic/Center will release your health information if asked to do so by a law enforcement official, and if permitted by law:

• In response to a court order;
• If required by state or federal law;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, Cookeville Medical Clinic/Center are unable to obtain the personÕs agreement;
• About a death Cookeville Medical Clinic/Center believe may be the result of criminal conduct;
• About criminal conduct at a Clinic facility; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
  

For Treatment

Cookeville Medical Clinic/Center may use your health information to provide you with medical treatment or services.  Cookeville Medical Clinic/Center may disclose your health information to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other Clinics personnel who are involved in taking care of you.  Different departments of Cookeville Medical Clinic/Center also may share medical information about you in order to coordinate the different things you need.  Cookeville Medical Clinic/Center also may disclose your health information to people outside Cookeville Medical Clinic/Center, such as other health care providers involved in providing medical treatment for you and to people who may be involved in your medical care, such as family members, clergy or others Cookeville Medical Clinic/Center use to provide services that are part of your care.

For Payment

Cookeville Medical Clinic/Center may use and disclose your health information so that the treatment and services you receive at Cookeville Medical Clinic/Center, or other health care providers from whom you receive treatment, may be billed to, and payment may be collected from, you, an insurance company or a third party.  For example, Cookeville Medical Clinic/Center may need to give information about treatment you received at Cookeville Medical Clinic/Center so that your health plan will pay Cookeville Medical Clinic/Center or reimburse you for your treatment.  Cookeville Medical Clinic/Center may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.  

For Health Care Operations

Cookeville Medical Clinic/Center may use and disclose your health information for Cookeville Medical Clinic/CenterÕ operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan.  These uses and disclosures are necessary to run Cookeville Medical Clinic/Center and make sure that all of Cookeville Medical Clinic/CenterÕ patients receive quality care.  For example, Cookeville Medical Clinic/Center may use your health information to review Cookeville Medical Clinic/Center treatment and services and to evaluate the performance of Cookeville Medical Clinic/CenterÕ staff in caring for you.  Cookeville Medical Clinic/Center may also combine health information about many patients to decide what additional services Cookeville Medical Clinic/Center should offer, what services are not needed, and whether certain new treatments are effective.  Cookeville Medical Clinic/Center may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students, and other personnel for review and learning purposes.  Cookeville Medical Clinic/Center may also combine the health information they have with health information from other health care providers to compare how Cookeville Medical Clinic/Center are doing and see where Cookeville Medical Clinic/Center can make improvements in the care and services Cookeville Medical Clinic/Center offer.  Cookeville Medical Clinic/Center may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.

For Appointment Reminders

Cookeville Medical Clinic/Center may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care at Cookeville Medical Clinic/Center.

For Treatment Alternatives

Cookeville Medical Clinic/Center may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services

Cookeville Medical Clinic/Center may use or disclose your health information to provide you with information on health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care

Cookeville Medical Clinic/Center may release your health information to a friend or family member who is involved in your medical care.  Cookeville Medical Clinic/Center may also give information to someone who helps pay for your care.  In addition, Cookeville Medical Clinic/Center may disclose your health information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research

Under certain circumstances, Cookeville Medical Clinic/Center may use and disclose your health information for research purposes.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patientsÕ need for privacy of their health information.  Before Cookeville Medical Clinic/Center use or disclose health information for research, the project will have been approved through this research approval process, but Cookeville Medical Clinic/Center may, however, disclose your health information to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave Cookeville Medical Clinic/Center.  Cookeville Medical Clinic/Center may ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at Cookeville Medical Clinic/Center.

For Workers' Compensation

Cookeville Medical Clinic/Center may release your health information to the extent necessary to comply with laws related to workers' compensation or similar programs.

Organ and Tissue Donation

If you are an organ donor, Cookeville Medical Clinic/Center may release your health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans

If you are a member of the armed forces, Cookeville Medical Clinic/Center may release your health information as required by military command authorities.  Cookeville Medical Clinic/Center may also release health information about foreign military personnel to the appropriate foreign military authority.

Coroners, Medical Examiners and Funeral Directors

Cookeville Medical Clinic/Center may release health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  Cookeville Medical Clinic/Center may also release medical information about patients of Cookeville Medical Clinic/Center to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities

Cookeville Medical Clinic/Center may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.  

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, Cookeville Medical Clinic/Center may release your health information to the correctional institution or law enforcement official.  This release would be necessary:  (i) for the institution to provide you with health care;  (ii) to protect your health and safety or the health and safety of others; or (iii) for the safety and security of the correctional institution.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than as stated above, Cookeville Medical Clinic/Center will not disclose your health information other than with your written authorization.  If you authorize Cookeville Medical Clinic/Center to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that Cookeville Medical Clinic/Center maintain:

Right to Request Restrictions

You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Cookeville Medical Clinic/CenterÕ disclosure of your health information to someone involved in the payment of your care.  However, Cookeville Medical Clinic/Center are not required to agree to your request.  If you wish to make a request for restrictions, please make your request in writing to the Privacy Officer.

Right to Receive Confidential Communications

You have the right to request that Cookeville Medical Clinic/Center communicate with you in a certain way if you feel the disclosure of your health information could endanger you.  For example, you may ask that Cookeville Medical Clinic/Center only communicate with you at a certain telephone number.  If you wish to receive confidential communications, please make your request in writing to the Privacy Officer.  Cookeville Medical Clinic/Center will attempt to honor your reasonable requests for confidential communications.

Right to Inspect and Copy Your Health Information

You have the right to inspect and copy health information that may be used to made decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes.  A request to inspect and copy records containing your health information must be made in writing to the Privacy Officer.  If you request a copy of your health information, Cookeville Medical Clinic/Center may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request.

Right to Amend Your Health Information

If you believe that your health information records are incorrect or incomplete, you may request that Cookeville Medical Clinic/Center amend the records.  That request may be made as long as the information is maintained by Cookeville Medical Clinic/Center.  A request for an amendment of records must be made in writing to the Privacy Officer.  Cookeville Medical Clinic/Center may deny the request if it does not include a reason to support the amendment.  The request also may be denied if your health information records were not created by Cookeville Medical Clinic/Center, if the health information you are requesting to amend is not part of Cookeville Medical Clinic/CenterÕ records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if Cookeville Medical Clinic/Center determine the records containing your health information are accurate and complete.

Right to an Accounting of Disclosures

You have the right to request a list of disclosures of your health information made by Cookeville Medical Clinic/Center.  The request must be made in writing to the Privacy Officer.  The request should specify the time period for which you are requesting the information, but may not start earlier than July 15, 2007.  Accounting requests may not be made for periods of time going back more than six (6) years.  Cookeville Medical Clinic/Center will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.  Cookeville Medical Clinic/Center will inform you in advance of the fee, if applicable.

Right to a Paper Copy of this Notice

You have a right to receive a paper copy of this Notice.  To obtain a paper copy, please contact the Privacy Officer.  You also may obtain a print a copy of the current version of Cookeville Medical Clinic/CenterÕ Notice from its website at www.ehclinics.com.
 
DUTIES OF Cookeville Medical Clinic/Center

Cookeville Medical Clinic/Center are required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. Cookeville Medical Clinic/Center are required to abide by the terms of this Notice, which may be amended from time to time.  Cookeville Medical Clinic/Center reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains.  If Cookeville Medical Clinic/Center change their policies and procedures, Cookeville Medical Clinic/Center will revise the Notice and will post a copy of the revised Notice in each of its facilities.  You have the right to express complaints to Cookeville Medical Clinic/Center and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated.  Any complaints to Cookeville Medical Clinic/Center should be made in writing to Cookeville Medical Clinic/CenterÕ Privacy Officer.  Cookeville Medical Clinic/Center encourage you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON / PRIVACY OFFICER

You may write to the the Privacy Officer that Cookeville Medical Clinic/Center have dedicated as its contact person for all issues regarding your privacy rights.  The Privacy Officer for Cookeville Medical Clinic/Center is:

Rick Carroll
Cookeville Medical Clinic/Center
225 N Willow Ave
Cookeville,TN  30501
Telephone: 931-525-5454 ext.2304
Facsimile: 706-364-3285

EFFECTIVE DATE

This Notice is effective June 26, 2008.