Cibola General Hospital, Inc.
This notice describes how information about you may be used and disclosed and how you can get access to this information at Cibola General Hospital and at Cibola Family Health Center. Please review it carefully.
Notice of Privacy Practices
Understanding How Your Protected Health Information is Used.
Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test result, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health information or medical record, serves as a:
Basis for planning your care and treatment
Means of communication among the many health professionals who contribute to your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
A tool in educating health professionals
A tool for patient safety
A source of data for medical research
A source of information for public health officials charged with improving the health of the nation
A source of data for facility planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to:Ensure its accuracy
Better understand who, what, when, where, and why others may access your health information
Make more informed decisions when authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you.
You have the right to:
Request a restriction on certain uses and disclosures of your protected health information as provided by 45 CFR 164.522: You have a right
to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved
in your care or the payment for your care, like a family member. We are not required to honor all requests for restrictions on uses and
disclosure of protected health information. To request restrictions, you must make your request in writing. In your request, you must tell us:
What information you want to limit and protect;
Whether you want to limit our use, disclosure or both; and
To whom you want the limits to apply, for example, disclosure to your spouse.
Once we agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment). You may
cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancelation and
continue to apply the restriction to information collected before the cancelation.
You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care
operations. We are required to honor your request if the health care item or service is paid out of pocket and paid in full. This restriction
does not apply to use or disclosure of your protected health information related to your medical treatment, but only applies to use and
disclosure to a health plan
Obtain a paper copy of the notice of information practices upon request
Inspect and obtain a copy of your health record as provided for in 45-CFR 164.524: You have the right to inspect and copy health records
and medical information that may be used to make decisions about your care.
To inspect and copy health records or medical information or to receive an electronic copy of the health records or medical information that
may be used to make decisions about you, you must submit a written request: and
If you request a paper copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your
If the facility uses or maintains an electronic health record with respect to your medical information, you have the right to obtain an
electronic copy of the information if you so choose.
You may direct the facility to transmit the copy to another entity or person that you designate provided the choice is clear, concise, and
The facility may charge a fee equal to its labor cost in providing the electronic copy.
Amend your health record as provided in 45 CFR 164.524
Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
Request communications of your health information by alternative means or at alternative locations
Revoke your authorization to use or disclose health information except to the extent that action has already been taken
Most uses and disclosures of protected health information regarding psychotherapy notes will not be made without your prior written
Most uses and disclosures of protected health information for marketing purposes, including subsidized communications with you, whether
about appointments, treatment options and treatment reminders, and the sale of protected health information will not be made without your
prior written authorization.
If you are going to be contacted about fundraising, you may opt out and request that you not receive such contacts and communications.
Any uses and disclosure of protected health information other than those permitted by our Privacy Practice and the related State and
Federal laws will be made only with your written authorization or the written authorization for the individual involved.
We will not disclose any genetic information about you to anyone for underwriting purposes without your written authorization.
This organization is required to:
Maintain the privacy of your protected health information
Provide you with a notice as to our legal duties and privacy practice with respect to information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
You will receive a notification from us if there is a breach of our Privacy Practices or breach of unsecured protected health information.
We reserve the right to change our practice and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide a new notice with the changes to every patient upon registration. A copy of our Notice of Privacy Practices will be available where you receive medical care, consultation, and treatment at Cibola General Hospital and Cibola Family Health Center. We will not use or disclose your health information without your authorization, except as described in this notice.
For More Information or to Report a Problem If you have questions and would like additional information, you may contact the Privacy Officer at 505-287-5240, or if you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer at Cibola General Hospital, 1016 E. Roosevelt Avenue. There will be no retaliation for filing a complaint. Secretary of the Department of Health and Human Services The U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 (202) 619-0257 Toll Free (877) 696-6775
Examples of Disclosures for Treatment, Payment and Health Care Operations We will use your protected health information for treatment.
For Example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observation. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you are discharged from the hospital. We will use your protected health information for payment.
For Example: A bill may be sent to you or to a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your protected health information for regular health care operations.
For Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.
This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also disclose your protected health information for the following activities:
Business Associates: There are some services provided in our organization through contracts with Business Associates. Examples include physician services in the Emergency Department, and Radiology, or Laboratory testing. When these services are contracted, we may disclose your protected health information to our Business Associates so that they can perform the job we have asked them to do and bill you or your third party payer for services rendered. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.
Facility Directory: Unless you notify us that you have opted out of the hospital's directory, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. Religious affiliation may be provided to members of the clergy. If you object to having your protected medical information released, we will not be able to tell your family or friends your room number or that you are in the hospital.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with family: Health Care professionals, using their best judgement may disclose to a family member, or relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care, appointment reminders, or payment related to your care.
Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.
Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may opt out of receiving these types of contacts and communications.
Food and Drug Administration (FDA): We may disclose to the FDA, health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Worker's Compensation: We may disclose health information to the extent authorized by, and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.
Public Health and Safety: As required by law, we may disclose your health information to public health, health oversight, or legal authorities charged with preventing misconduct, abuse and neglect, or controlling disease, injury, or disability.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health and the health and safety of other individuals.
Law Enforcement: We may disclose health information for law enforcement, purposes as required by law or in response to a valid subpoena or Court Order.
EFFECTIVE DATE / REVISION DATE: November 18, 2013