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Madison County Community Health Centers, Inc.



This Notice describes privacy practices of Madison County Community Health Centers, Inc. (MCCHC) including it centers and outreach entities, including: the medical staffs of MCCHC; all employees, staff, trainees, departments and affiliated entities of MCCHC; and any volunteer group we allow to help you while you are receiving care under the MCCHC's auspices.

I. Duty: Our duty to Safeguard Your Protected Health Information:

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for your health care is considered “Protected Health Information” (“PHI”). We understand that medical information about you and your health is personal and we are committed to protecting medical information about you. We are required by law to make sure that your PHI is kept private and to give you this Notice about our legal duties and privacy practices, which explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.

We must follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we change this Notice, we will post a new Notice in patient registration and/or patient waiting areas. The Notice will contain the effective date on the first page, top right-hand corner. You may request a copy of the new notice on the Patient Portal on our website at www.mcchc.org. We will also make available a copy of the Notice in effect each time you are seem at the clinic as a patient, or receive health care services from other health care providers within the Madison County Community Health Centers, Inc. and its affiliates.

II. How We May Use and Disclose Your Protected Health Information:

We use and disclose PHI for a variety of reasons. For certain uses/disclosures, we must get your written authorization. However, the law provides that we may make some uses/disclosures without your authorization. The following section offers more description and examples of our potential uses/disclosures of your PHI.

•   Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Generally, we may use/disclose your PHI:

For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team, our central pharmacy staff, or with a specialist to whom you have been referred. We may also share PHI with health care provider licensing bodies like the Indiana State Department of Health.

To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may release portions of your PHI to Medicare/Medicaid, a private insurer or group health plan to get paid for services that we delivered to you. Release of your PHI to the state Medicaid agency might also be necessary to determine your eligibility for publicly funded services.

For health care operations: We may use/disclose your PHI in the course of our operations. For example, we may use your PHI or your answers to a patient satisfaction survey in evaluating the quality of services provided by our staff, or disclose your PHI to our auditors or attorneys for audit or legal purposes. Since we are an integrated system, we may share your PHI with designated staff within the Community Health Network, for treatment, payment or operations purposes.

Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home. We may also call your home and leave a message on your answering machine or voice mail. (See Section III about confidential communication.)

Treatment alternatives: We may contact you about possible treatment options or alternatives, or other health-related benefits or services that may interest you.

•     Uses and Disclosures Requiring Authorization: For uses and disclosures other than treatment, payment and operations purposes, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. You may revoke an authorization, in writing, any time to stop future uses/disclosures. If you revoke your authorization, we will stop using/disclosing your PHI for the purposes or reasons covered by your written authorization. You understand that we are unable to take back disclosures we have already made with your permission and that we are required to keep our records of the care we provided to you. (See Section VII for instructions for revoking an authorization.) We cannot refuse to treat you if you refuse to sign an authorization to release PHI, unless services provided are solely to create health records for a third party, such as physical and drug testing for an employer or insurance company; or if treatment provided is research-related and authorization is required for the use of health information for research purposes.

•     Uses and Disclosures Not Requiring Authorization: The law provides that we may use/disclose your PHI without your authorization in the following circumstances:

When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, for FDA-regulated products or activities, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority, such as reports of tuberculosis cases or births and deaths.

For health oversight activities: We may disclose PHI to the Indiana State Department of Health or other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.

Relating to decedents: We may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.

For research purposes: In certain circumstances, and under supervision of the Institutional Review Board of the Community Health Network we may disclose PHI in order to assist medical research, based solely on your voluntary consent to participate in.

To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

Law enforcement: We may disclose PHI to a law enforcement official in circumstances such as: in response to a court order; to identify a suspect, witness or missing person; about crime victims; about a death that we may suspect is the result of criminal conduct; or criminal conduct at the hospital or health care facility.

For specific government functions: We may disclose PHI of military personnel and veterans in certain situations; to correctional facilities in certain situations; and for national security and intelligence reasons, such as protection of the President.

Workers’ Compensation: We may disclose your PHI to your employer for Workers’ Compensation or similar programs that provide benefits for work-related illness or injuries.

Inmates: An inmate does not have rights listed in this Notice of Privacy Practices. The rights listed in this notice will not apply to inmates of a correctional institution.

•     Uses and Disclosures Requiring You to Have an Opportunity to Object: In the following situations, we may disclose your PHI if we inform you about the disclosure in advance and you have the opportunity to agree to or prohibit or restrict the disclosure. However, if there is an emergency situation and you cannot be given the opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

To families, friends or others involved in your care: We may share with these people information directly related to your family’s, friend’s or other person’s involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.

Disaster relief: We may release your PHI to a public or private relief agency for purposes of coordinating notifying your family and friends of your location, condition or death in the event of a disaster.

III. Your Rights Regarding Your Protected Health Information:

You have the following rights relating to your protected health information:

To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. You must make your request in writing. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. If agreed upon, these restrictions will only apply to the Madison County Community Health Centers, Inc. affiliates listed in the beginning of this Notice. You understand that we are not able to take back disclosures already made. We cannot agree to limit uses/disclosures that are required by law.

To request confidential communication: You have the right to ask that we send you information at an alternative address or by an alternative means, such as contacting you only at work. You must make your request in writing. We must agree to your request as long as it is reasonably easy for us to do so.

To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed. You have the right to choose what portions of your information you want copied and to have information on the cost of copying in advance.

To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. Written requests must include a reason that supports your request. We will respond within 60 days of receiving your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial reviewed, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.

To find out what disclosures have been made: You have the right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for which you gave your written authorization. (This is called an accounting of disclosures.) Your request can relate to disclosures going as far back as six years. The list will not include any disclosures made before April 14, 2003, for national security purposes, for treatment, payment or operations purposes, or to law enforcement officials or correctional facilities. Your request must be in writing. We will respond to your written request for such a list within 60 days of receiving it. There will be no charge for the first list requested each year. There may be a charge for subsequent requests.

To receive a paper copy of this Notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by email upon request. To obtain a copy of this Notice, contact: Patient Access at (765) 641-0255 or download a copy.

IV. How to Complain about our Privacy Practices:

If you think we may have violated your privacy rights, or if you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section V. below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized if you file a complaint.

V. Contact Person for Information or to Submit a Complaint:

If you have questions about this Notice or any complaints about our privacy practices, please contact: MCCHC Corporate Compliance Officer, 1547 Ohio Avenue, Anderson, IN, 46016, 765/641-0255-Ext. 413.

VI. Contact Person for Copies of PHI and Requests for Amendments/Corrections to PHI:

For written requests for copies of PHI or for amendments/corrections to medical information contained in your PHI, contact the Medical Records Dept., (in writing) 1547 Ohio Avenue, Anderson, IN, 46016

VII. Instructions for Revoking an Authorization

You may revoke an authorization to use or disclose your PHI, in writing, except 1) to the extent that action has been taken in reliance on the authorization, or 2) if the authorization was obtained as a condition of obtaining insurance coverage and other law provides the insurer with the right to contest a claim under the policy. Your written revocation must include the date of the authorization, the name of the person or organization authorized to receive the PHI, your signature and the date you signed the revocation. Send your written revocation to: Medical Records Dept., 1547 Ohio Avenue, Anderson, IN, 46016

Effective Date:             April 14, 2003

Last Review Date: January 3, 2017

Madison County Community Health Centers, Inc.



This summary describes how medical information about you may be used or disclosed and how you can access the information.

We have a legal duty to safeguard your medical information. We may use your protected health information (PHI) for your care and treatment, for payment for your care and services and for our internal operations. For most other purposes, we must get your written permission to use or disclose your PHI.

Unless you object, we may include your phi for our patient directory, or disclose your phi to your family, friends or others involved in your care or who are responsible to pay for your care. We may also use your phi to find your family or friends and tell them that you have been admitted to the hospital and of your condition or death.

You have the following rights regarding your PHI:

  • The right to request restrictions on our uses and disclosures of your PHI. We will

          review your request but are not required to agree to the restrictions.

  • The right to request confidential communication at another address or phone

          number. We must agree as long as it is reasonably easy for us to do.

  • The right to look at and get a copy of your PHI.
  • The right to correct or amend incorrect information about you.
  • The right to find out to whom we have disclosed your phi that is not used or      

         disclosed for treatment, payment or health care operations purposes, or that you    

            have authorized in writing.

  • The right to receive a paper copy of our notice of privacy practices.

If you believe your rights to privacy of your health information have been violated, you may make a complaint in writing to Madison County Community Health Center Corporate Compliance Officer at 1547 Ohio Avenue P.O. Box 349, Anderson, Indiana 46015. You may also make a complaint in writing to the Secretary of the Department of Health and Human Services. Please refer to the Madison County Community Health Centers, Inc. Notice of Privacy Practices for a complete listing of HIPAA requirements for uses and disclosures of PHI.

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