HIPAA

Kachelmacher Memorial, Inc. Practice Privacy Statement

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment to you or who may be consulted by staff members.

Law Enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government-mandated reporting.

Public Health Reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other Uses and Disclosures Require Your Authorization.

Disclosure of your health information or its use for any purpose other than listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. This statement must be dated and signed. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Additional Uses of Information

Appointment Reminders. Your information will be used by our staff to either call you or send you appointment reminders.

Individual Rights

You have certain rights under the federal privacy standards. These include:

1. 1. The right to request restrictions on the use and disclosure of your protected health information.
   2. The right to receive confidential communications concerning your medical condition and treatment.
   3. The right to inspect and copy your protected health
   4. information. Copying and postage fees apply.
   5. The right to amend or submit corrections to your health
   6. information.
   7. The right to receive an accounting of how and to whom your protected health information has been disclosed.
   8. The right to receive a printed copy of this notice.

Kachelmacher Memorial, Inc. Duties.

We are required by Federal Law to maintain the privacy of your protected health information and to provide you with the notice of privacy practices.

We are also required by law to abide by the privacy policies and practices outlined in this notice.

Right to revise privacy notices. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our practices or policies may be required by federal and state laws and regulations. Upon request we will provide you with the most recent update or revised notice on any office visit. Any revision will apply to all protected health information that we maintain.

Request to inspect protected health information. You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, require that requests to copy or inspect protected health information be submitted in writing. You may obtain a form to request access to your records by contacting Kachelmacher Memorial Inc. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

If you believe that your privacy rights have been violated. You may contact us in writing, describing the cause of your concern to Kachelmacher Memorial Inc., at the* address listed below.

You will not be penalized or otherwise retaliated against for filing a complaint.

This notice is effective on April 14, 2003 and thereafter.

Kachelmacher Memorial, lnc. 755 State Route 664 N. Post Office Box 348, Logan, Ohio 43138