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HIPAA Privacy Statement

Monroe Community Hospital Notice Of Privacy Practices 

To download a copy of this policy, please click here.


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. This notice is distributed in compliance with HIPAA (Health Insurance Portability and Accountability Act of 1996 and the HIPAA Omnibus Rule 2013), and is designed to assist you in understanding and protecting your health information.


Our facility uses your Protected Health Information for treatment, to obtain payment for our services and for our operational purposes, such as improving the quality of care we provide to you. We are committed to maintaining your confidentiality and protecting your health information. We are required by law to provide you with this Notice, which describes our health information privacy practices and those of affiliated health care providers that provide care at our facility.


This Notice applies to all information and records related to your care that our facility workforce members and Business Associates have received or created. It also applies to independent health care providers and their employees, such as physicians, nurse practitioners, physicians assistants, psychologists, nurses, certified nursing assistants, dietitians, dental professionals, lab technicians, audiologists, therapists, radiology technicians, and their students, who provide care to you in a way that is integrated with our services. It informs you about the possible uses and disclosures of your Protected Health Information and describes your rights and our obligations regarding your Protected Health Information.


We are required by law to:

  • Maintain the privacy of your Protected Health Information;

  • Provide to you this detailed Notice of our legal duties and privacy practices relating to your Protected Health Information;

  • Notify you should breach of your Protected Health Information be discovered;

  • Disclose Protected Health Information only with authorization from the patient.

  • Abide by the terms of this Notice that are currently in effect.


We reserve the right to change the terms of this Notice, and will notify you or your personal representative by letter if we make any material changes to this Notice.




In accepting admission to Monroe Community Hospital, you agree to allow us to share information about you for treatment, payment, and healthcare operations. Here are examples of how we may use and disclose your health information


For Treatment. Our staff and affiliated health care professionals may review and record information in your record about your treatment and care. We will use and disclose this health information to health care professionals in order to treat and care for you. For example, a physician may consult with another physician located at another location to determine how to best diagnose and treat you.


For Payment. Our facility may use and disclose your Protected Health Information to others in order for the facility to bill for your health care services and receive payment. For example, we may include your health information in our claim to Blue Cross/Blue Shield or Medicare in order to receive payment for services provided to you. We may also disclose your health information to other health care providers so that they can receive payment for your services.


For Health Care Operations. We may use and disclose your Protected Health Information to others for our facility's business operations. For example, we may use Protected Health Information to evaluate our facility's services, including the performance of our staff, and to educate our staff.




Business Associates. We may share your Protected Health Information with our vendors and agents who help us with obtaining payment or carrying out our business functions. For example, we may give your health information to a billing company to assist us with our billing for services, or to a law firm or an accounting firm that assists us in complying with the law and or improving our services.


Facility Directory. Unless you object, we may include general information about you in our facility directory. This information may include your name, location in the facility, general condition and religious affiliation. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to any member of the clergy even if they don't ask for you by name. To opt out of the facility directory, please contact your social worker who will facilitate your request to fill out the Opt-Out Facility Directory form.


Family and Friends Involved in Your Care. Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.


Disaster Relief. We may disclose your Protected Health Information to an organization assisting in a disaster relief effort.


Public Health Activities. As required by law, the facility may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.


Health Oversight Activities. We may disclose your Protected Health Information to health oversight agencies authorized by law to conduct audits, investigations, inspections and licensure actions or other legal proceedings. These agencies provide oversight for the Medicare and Medicaid programs, among others.


Reporting Victims of Abuse, Neglect or Domestic Violence. If we have reason to believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your Protected Health Information to notify a government authority if required or authorized by law, or if you agree to the report.


Law Enforcement. We may disclose your Protected Health Information for certain law enforcement purposes or other specialized governmental functions.


Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of certain judicial or administrative proceedings.


Research. In general, we will request that you sign a written authorization before using your Protected Health Information or disclosing it to others for research purposes. However, we may use or disclose your health information without your written authorization for research purposes provided that the research has been reviewed and approved by a special Privacy Board or Institutional Review Board.


Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiner, funeral director, or if you are an organ donor, to an organization involved in the donation of organs and tissue.


To Avert a Serious Threat to Health or Safety. We may use and disclose your Protected Health Information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.


Military and Veterans. If you are a member of the armed forces, we may use and disclose your Protected Health Information as required by military command authorities. We may also use and disclose Protected Health Information about foreign military personnel as required by the appropriate foreign military authority.


Workers' Compensation. We may use or disclose your Protected Health Information to comply with laws relating to workers' compensation or similar programs.


National Security and Intelligence Activities; Protective Services. We may disclose health information to authorized federal officials who are conducting national security and intelligence activities or as needed to provide protection to the President of the United States, or other important officials.

As Required By Law. We will disclose your Protected Health Information when required by law to do so.


Treatment Alternatives and Health-Related Benefits. The facility may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.


Fundraising. The facility may contact you or your personal representative to raise money to help us operate. We may also share your demographic information with the MCH Foundation who may contact you or your personal representative to raise money on our behalf. You have the opportunity to opt out or restrict your receiving fundraising communications. Please contact your social worker who will facilitate with you the completion of the Fundraising Opt-Out form.


Marketing Activity. The facility may disclose your information for marketing purposes if the communication is in the form of a face-to-face communication made directly with you or to provide a promotional gift of nominal value. You have the opportunity to opt out or restrict your receiving marketing communications. Contact your social worker who will facilitate a Fundraising Opt-Out form to complete and to be filed in your medical record. Disclosure of your information for other marketing purposes will require your authorization.

Under no circumstances will Monroe Community Hospital sell your Protected Health Information for marketing purposes.



Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. To implement this requirement, the facility must obtain information from every resident. This information also is used by the Federal Centers for Medicare & Medicaid Services (CMS) to ensure that the facility meets quality standards and provides appropriate care to all residents. For this purpose, as of June 22, 1998, all such facilities are required to establish a database of resident assessment information, and to electronically transmit this information to the HCFA contractor in the State government, which in turn transmits the information to HCFA. Because the law requires disclosure of this information to Federal and State sources as discussed above, a resident does not have the right to refuse consent to these disclosures.


These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long-Term Care System of Records. Authority for collection of information, including Social Security Number and whether disclosure is mandatory or voluntary. Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.


1. Principal Purposes For Which Information Is Intended To Be Used. The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services.


2. Routine Uses. The primary use of this information is to aid in the administration of the survey and certification of Medicare/Medicaid long-term care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its Stated purpose. The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-0528, published in the Federal Register at Vol. 72, no. 52/Monday, March 19, 2007. Information from this system may be disclosed, under specific circumstances (routine uses), which include: (1)To support agency contractors, consultants or grantees who have been engaged by the agency to assist in accomplishment of a CMS function; (2) assist another Federal or state agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds; (3) assist Quality Improvement Organizations to perform Title XI or Title XVIII functions; (4) assist insurance companies, underwriters, third party administrators, employers, group health plans for purposes of coordination of benefits with the Medicare Program; (6) the Federal Department of Justice, court, or adjudicatory body in litigation; (7) to support a national accrediting organization to enable them to target potential or identified problems with accredited facilities; (8) assist a CMS contractor in the administration of a CMS-administered health benefits program; (9) to assist another Federal agency that administers or that has the authority to investigate potential fraud, waste or abuse in a health benefits program funded in whole or part by Federal funds.


3. Effect on Individual Of Not Providing Information. The information contained in the Long-Term Care Minimum Data Set is generally necessary for the facility to provide appropriate and effective care to each resident. If a resident fails to provide such information, for example on medical history, inappropriate and potentially harmful care may result. Moreover, payment for such services by third parties, including Medicare and Medicaid, may not be available unless the facility has sufficient information to identify the individual and support a claim for payment.




We will use and disclose your Protected Health Information other than as described in this Notice or required by law only with your written Authorization. You may revoke your Authorization to use or disclose Protected Health Information in writing, at any time. To revoke your Authorization, contact the Health Information Services (HIS) department. If you revoke your Authorization, we will no longer use or disclose your Protected Health Information for the purposes covered by the Authorization, except where we have already relied on the Authorization.




You have the following rights with respect to your health information. If you wish to exercise any of these rights, you should make your request to the Health Information Services Director.


Right of Access to Protected Health Information. You have the right to request, either orally or in writing, to inspect and obtain a copy of your Protected Health Information, subject to some limited exceptions. We must allow you to inspect your records within 24 hours of your request. If you request copies of the records, we must provide you with copies within 2 workdays of that request. We may charge a reasonable fee for our costs in copying and mailing your requested information. In certain limited circumstances, we may deny your request to inspect or receive copies. If we deny access to your Protected Health Information, we will provide you with a summary of the information, and you have a right to request review of the denial. We will provide you with information on how to request a review of our denial and how to file a complaint with us or the Secretary of the Department of Health and Human Services.


Right to Request Restrictions. You have the right to request restrictions on the way we use and disclose your Protected Health Information for our treatment, payment or health care operations. You also have the right to restrict your Protected Health Information that we disclose to a family member, friend or other person who is involved in your care or the payment for your care.

You have the right to restrict disclosure of Protected Health Information to your insurer if you fully pay for treatment out-of-pocket. We are not required to agree to your requested restriction, and in some cases, the law may not permit us to accept your restriction. However, if we do agree to accept your restriction, we will comply with your restriction except if you are being transferred to another health care institution, the release of records is required by law, or the release of information is needed to provide you emergency treatment.


Right to an Accounting of Disclosures. You have the right to request an "accounting" of our disclosures of your Protected Health Information. This is a listing of certain disclosures of your Protected Health Information made by the facility or by others on our behalf, but does not include disclosures made for treatment, payment and health care operations or certain other exceptions. You must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. For example, you may request a list of disclosures the facility made between May 1, 2003 and May 1, 2004. You are entitled to one free accounting within one 12-month period. For additional requests, we may charge you our costs. We will usually respond to your request within 60 days. Occasionally, we may need additional time to prepare the accounting. If so, we will notify you of our delay, the reason for the delay, and the date when you can expect the accounting.


Psychotherapy Notes. Psychotherapy notes are recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversations during a private counseling session or a group, joint or family counseling session. These notes are separate from the patient's medical record. The disclosure of these notes will require a separate authorization.

Right to Request Amendment. If you think that your Protected Health Information is not accurate or complete, you have the right to request that the facility amend such information for as long as the information is kept in our records. Your request must be in writing and state the reason for the requested amendment. We will usually respond within 60 days, but will notify you within 60 days if we need additional time to respond, the reason for the delay and when you can expect our response. We may deny your request for amendment, and if we do so, we will give you a written denial including the reasons for the denial and an explanation of your right to submit a written statement disagreeing with the denial.


Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may obtain a copy of this Notice at our website.

Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example, you can request that we speak to you only at certain private locations in the facility. We will accommodate your reasonable requests.




If you believe that your privacy rights have been violated, you may file a complaint in writing to Monroe Community Hospital or with the Office of Civil Rights in the U.S. Department of Health and Human Services (HHS). To file a complaint with the facility, contact the Privacy Officer in Health Information Services at 585-760-6089. No one will retaliate or take action against you for filing a complaint. We cannot require you to waive your rights to file a complaint to HHS as a condition of the provision of treatment or payment.




We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all Protected Health Information already received and maintained by the facility as well as for all Protected Health Information we receive in the future. We will post a copy of the current Notice in the facility. In addition, we will provide a copy of the revised Notice to all residents by delivering a hard copy to them or their personal representatives.




If you have any questions about this Notice or would like further information concerning your privacy rights, please contact the Privacy Officer at 760-6065.


Effective Date of this Notice: September 23, 2013

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