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Privacy Policy

CGH Medical Center
Notice of Privacy Practices
HIPAA 164.520

Effective date: 3/1/2020

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.

If you have any questions about this notice, please contact the CGH Privacy Officer at:

CGH Medical Center
100 E. Le Fevre Road
Sterling, IL 61081

Who will follow this notice

This notice describes the information privacy practices followed by our employees, staff and other personnel.

Your health information

This notice applies to the information and records we have about you, your health, health status and the healthcare and services you receive from CGH Medical Center. Your health information may include information created and received by CGH Medical Center; may be in the form of written or electronic records or spoken words; and may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

How we may use and disclose health information about you

We may use and disclose health information for the following purposes:

For treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, staff or other personnel who are involved in taking care of you and your health.

For example, your doctor may be treating you for a heart condition and may need to know if you have other health problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.

Different personnel in our organization may share information about you and disclose information to people who do not work for CGH Medical Center in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. Family members and other healthcare providers may be part of your medical care outside this office and may require information about you that we have. We will request your permission before sharing health information with your family or friends unless you are unable to give permission to such disclosures due to your health condition.

For payment. We may use and disclose health information about you so that the treatment and services you receive at CGH Medical Center may be billed to and payment may be collected from you, an insurance company or a third party.

For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We 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 pay for the treatment.

For healthcare operations. We may use and disclose health information about you in order to run CGH Medical Center and make sure that you and our other patients receive quality care.

For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient or whether certain new treatments are effective.

We may also disclose your health information to health plans that provide you insurance coverage and other healthcare providers that care for you. Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage healthcare and services, train staff, and comply with the law.

Fundraising. We may contact you to ask for your help with different fundraising campaigns. You have the right to opt out of fundraising communications with each solicitation.

Please notify us if you do not wish to be contacted during fundraising campaigns. If you advise us in writing that you do not wish to receive such communications, we will not use or disclose your information for these purposes.

Special situations

We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

To avert a serious threat to health or safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required by law. We will disclose health information about you when required to do so by federal, state or local law.

Research. We may use and disclose health information about you for research projects without your authorization, provided we receive an approved waiver by an institutional review board/privacy board or the researcher has represented that the use or disclosure of your protected health information is solely to prepare a research protocol or for similar purpose preparatory to research. We will ask you for your 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 the office.

Organ and tissue donation. We will share your health information to organ and tissue procurement organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.

Essential government functions. We may use or disclose your protected health information for certain essential government services. If you are or were a member of the armed forces or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers' compensation. We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public health risks. We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, nonaccidental physical injuries, reactions to medications, or problems with products. For example, to alert a person who may have been exposed to a disease or may be a risk for contracting or spreading a disease.

Health oversight activities. We may disclose health information to a health oversight agency for audits, investigations, inspections or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs and compliance with civil rights laws.

Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

Law enforcement. We may release your health information if asked to do so by a law enforcement official under the following circumstances: (1) as required by law in response to a court order, subpoena, warrant, summons or similar process; (2) to identify or locate a suspect, fugitive, material witness or missing person; (3) in response to law enforcement request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person's death, if we suspect that criminal activity caused the death; (5) if we believe the health information is evidence of a crime that occurred on our premises; and (6) in an medical emergency not on our premises, when necessary to inform law enforcement.

Coroners, medical examiners and funeral directors. We 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.

Information not personally identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Family and friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment, that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room or the hospital during treatment or while treatment is discussed.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person's involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies or x-rays.

Medical power of attorney. If you give someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act on your behalf.

Information sharing through participation in a Health Information Exchange. We participate in 2 health information exchanges (HIEs) through our electronic medical record software. The names of these two HIEs are CommonWell Health Alliance and Carequality. As a participant, we make patient medical information available electronically to other participating hospitals, physicians and other authorized users for treatment, payment and healthcare operations purposes. In the future, we may also participate directly in additional vendor, regional, state or federal HIEs. Our participation in CommonWell and Carequality has been designed to comply with federal and state privacy and security laws. Access to your medical information is limited to authorized users who confirm that they will comply with these laws. If you do not want your health or medical information to be shared with other participants in CommonWell, Carequality or other HIEs, please contact our Privacy Officer as identified at the bottom of this form to request and receive an Opt-Out Form and return the completed form to us. Please note that if you choose to opt out after your information has been shared, any information that was previously shared will likely still be available to other participants, although no new information will be shared. Making your information available for treatment through an HIE is not a condition of receiving care.

Other uses and disclosures of health information

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. Examples of disclosures requiring your authorization include disclosures to your partner, spouse, children and legal counsel.

The following uses and disclosures will be made ONLY with your specific, written Authorization:

For our marketing purposes. This does not including face-to-face communication about products or services that may be of benefit to you and about prescriptions you have already been prescribed.

For the purpose of selling your health information. We may receive payment for sharing your information for, as an example, public health purposes, research, and releases to you or others you authorize a release to as long as payment is reasonable and related to the cost of providing your health information.

Any disclosure of your psychotherapy notes. These are the notes that your behavioral health provider maintains that record your appointments with your provider.

If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

In some instances, we may need specific, written authorization from you in order to disclose certain types of specially-protected information such as HIV, substance abuse, mental health and genetic testing information for purposes such as treatment, payment and healthcare operations.

Uses and disclosures that require us to give you an opportunity to object

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

Your rights regarding health information about you

You have the following rights regarding health information we maintain about you:

Right to inspect and obtain a copy. You have the right to inspect and obtain a copy your health information, such as medical and billing records, that we keep and use to make decisions about your care. You must submit a written request to the CGH Privacy Officer in order to inspect and/or copy records of your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. A copy is usually provided within 30 days. 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. A modified request may include requesting a summary of your medical record.

If you request to view a copy of your health information, we will not charge you for inspecting your health information. If you wish to inspect your health information, please submit your request in writing to the CGH Privacy Officer.

You have the right to request a copy of your health information in electronic form if we store your health information electronically.

We may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by CGH Medical Center.

To request an amendment, complete and submit a medical record amendment/correction form to the CGH Privacy Officer.

We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny or partially deny your request if you ask us to amend information that:

  • We did not create, unless the person or entity that created the information is no longer available to make the amendment.
  • Is not part of the health information that we keep.
  • You would not be permitted to inspect and copy.
  • Is accurate and complete.

If we deny or partially deny your request for amendment, we will tell you why within 60 days. You have the right to submit a rebuttal and request the rebuttal be made a part of your medical record. We have the right to file a rebuttal responding to yours in your medical record. You also have the right to request that all documents associated with the amendment request (including rebuttal) be transmitted to any other party any time that portion of the medical record is disclosed.

Right to an accounting of disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, healthcare operations, when specifically authorized by you and a limited number of special circumstances involving national security, correctional institutions and law enforcement.

To obtain this list, you must submit your request in writing to the CGH Privacy Officer. It must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, 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.

Right to request restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information.

We are required to agree to your request if you pay for treatment, services, supplies and prescriptions "out of pocket" and you request the information not be communicated to your health plan for payment or healthcare operations purposes. There may be instances where we are required to release this information if required by law.

To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information to the CGH Privacy Officer.

Right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and submit the Request for Confidential Communication form to the CGH Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a paper copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.

To obtain such a copy, contact the CGH Privacy Officer.

Changes to this Notice

We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post the current notice at our location(s) with its effective date in the top right-hand corner. You are entitled to a copy of the notice currently in effect.

We will inform you of any significant changes to this Notice. This may be through our newsletter, a sign prominently posted at our location(s), a notice posted on our website or other means of communication.

Breach of health information

We are required to notify you of any breaches of your protected health information and will inform you if there is a breach of your health information.


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services at:

Office for Civil Rights Region V
U.S. Department of Health & Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

TO file a complaint with CGH Medical Center, you may contact the CGH Privacy Officer at 815.625.0400. You will not be penalized for filing a complaint.

CGH Medical Center
100 E. Le Fevre Road
Sterling, IL 61081