A Service of Knox Community Hospital
Welcome to Community Pediatrics and the office of Charles R. Bell, MD
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.

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The terms of this Notice of Privacy Practices apply to Knox Affiliated Health Services operating as
a clinically integrated health care arrangement composed of Knox Community Hospital and the
physicians and other licensed professionals seeing and treating patients at the hospital. The
members of this clinically integrated health care arrangement work and practice at Knox
Community Hospital, 1330 Coshocton Ave., Mount Vernon, Ohio 43050. All of the entities and
persons listed will share personal health information of our patients as necessary to carry out
treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients' personal health information and to
provide patients with notice of our legal duties and privacy practices with respect to your personal
health information. We are required to abide by the terms of this Notice so long as it remains in
effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary
and to make the new Notice effective for all personal health information maintained by us. You
may receive a copy of any revised notices at the Emergency Department registration, Central
Registration, front desk or the hospital web site at www.knoxcommhosp.org or a copy may be
obtained by mailing a request to Privacy Officer, Knox Community Hospital, 1330 Coshocton
Avenue, Mount Vernon, OH 43050.

USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your personal health
information for any purpose unless you have signed a form authorizing the use or disclosure.
You have the right to revoke that authorization in writing unless we have taken any action in
reliance on the authorization.

Uses and Disclosures for Treatment. We will make uses and disclosures of your personal
health information as necessary for your treatment. For instance, doctors and nurses and other
professionals involved in your care will use information in your medical record and information
that you provide about your symptoms and reactions to plan a course of treatment for you that
may include procedures, medications, tests, etc. We may also release your personal health
information to another health care facility or professional who is not affiliated with our
organization but who is or will be providing treatment to you. For instance, if, after you leave the
hospital, you are going to receive home health care, we may release your personal health
information to that home health care agency so that a plan of care can be prepared for you.

Uses and Disclosures for Payment. We will make uses and disclosures of your personal health
information as necessary for the payment purposes of those health professionals and facilities
that have treated you or provided services to you. For instance, we may forward information
regarding your medical procedures and treatment to your insurance company to arrange
payment for the services provided to you or we may use your information to prepare a bill to send
to you or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations. We will use and disclose your personal
health information as necessary, and as permitted by law, for our health care operations which
include clinical improvement, professional peer review, business management, accreditation and
licensing, etc. For instance, we may use and disclose your personal health information for
purposes of improving the clinical treatment and care of our patients. We may also disclose your
personal health information to another health care facility, health care professional, or health
plan for such things as quality assurance and case management, but only if that facility,
professional, or plan also has or had a patient relationship with you.

Our Facility Directory. We maintain a facility directory listing the name, room number, general
condition and, if you wish, your religious affiliation. Unless you choose to have your information
excluded from this directory, the information, excluding your religious affiliation, will be disclosed
to anyone who requests it by asking for you by name. This information, including your religious
affiliation, may be also be provided to members of the clergy. You have the right during
registration to have your information excluded from this directory.

Family and Friends Involved In Your Care. With your approval, we may from time to time
disclose your personal health information to designated family, friends, and others who are
involved in your care or in payment of your care in order to facilitate that person’s
involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or
facing an emergency medical situation, and we determine that a limited disclosure may be in your
best interest, we may share limited personal health information with such individuals without your
approval. We may also disclose limited personal health information to a public or private entity
that is authorized to assist in disaster relief efforts in order for that entity to locate a family
member or other persons that may be involved in some aspect of caring for you.

Business Associates. Certain aspects and components of our services are performed through
contracts with outside persons or organizations, such as auditing, accreditation, legal services,
etc. At times it may be necessary for us to provide certain of your personal health information to
one or more of these outside persons or organizations who assist us with our health care
operations. In all cases, we require these business associates to appropriately safeguard the
privacy of your information.

Fundraising. We may contact you to donate to a fundraising effort for or on our behalf. You
have the right to "opt-out" of receiving fundraising materials/communications and may do so by
sending your name and address to the Marketing Department, Knox Community Hospital, 1330
Coshocton Avenue, Mount Vernon, OH 43050 together with a statement that you do not wish to
receive fundraising materials or communications from us.

Appointments and Services. We may contact you to provide appointment reminders or test
results. You have the right to request and we will accommodate reasonable requests by you to
receive communications regarding your personal health information from us by alternative means
or at alternative locations. For instance, if you wish appointment reminders to not be left on voice
mail or sent to a particular address, we will accommodate reasonable requests. You may request
such confidential communication in writing and may send your request to Central Scheduling,
Knox Community Hospital, 1330 Coshocton Avenue, Mount Vernon, OH 43050.

Health Products and Services. We may from time to time use your personal health information
to communicate with you about health products and services necessary for your treatment, to
advise you of new products and services we offer, and to provide general health and wellness
information.

Research. In limited circumstances, we may use and disclose your personal health information
for research purposes. For example, a research organization may wish to compare outcomes of
all patients that received a particular drug and will need to review a series of medical records. In
all cases where your specific authorization has not been obtained, your privacy will be protected
by strict confidentiality requirements applied by an Institutional Review Board or privacy board
which oversees the research or by representations of the researchers that limit their use and
disclosure of patient information.

Other Uses and Disclosures. We are permitted or required by law to make certain other uses
and disclosures of your personal health information without your consent or authorization.

- We may release your personal health information for any purpose required by law;

- We may release your personal health information for public health activities, such as required
reporting of disease, injury, and birth and death, and for required public health investigations;

- We may release your personal health information as required by law if we suspect child abuse or
neglect; we may also release your personal health information as required by law if we believe
you to be a victim of abuse, neglect, or domestic violence;

- We may release your personal health information to the Food and Drug Administration if
necessary to report adverse events, product defects, or to participate in product recalls;

- We may release your personal health information to your employer when we have provided
health care to you at the request of your employer to determine workplace-related illness or
injury; in most cases you will receive notice that information is disclosed to your employer;

- We may release your personal health information if required by law to a government oversight
agency conducting audits, investigations, or civil or criminal proceedings;

- We may release your personal health information if required to do so by subpoena or discovery
request; in some cases you will have notice of such release;

- We may release your personal health information to law enforcement officials as required by law
to report wounds and injuries and crimes;

- We may release your personal health information to coroners and/or funeral directors consistent
with law;

- We may release your personal health information if necessary to arrange an organ or tissue
donation from you or a transplant for you;

- We may release your personal health information if in limited instances if we suspect a serious
threat to health or safety;

- We may release your personal health information if you are a member of the military as
required by armed forces services; we may also release your personal health information if
necessary for national security or intelligence activities; and

- We may release your personal health information to workers' compensation agencies if
necessary for your workers' compensation benefit determination.

Ohio law requires that we obtain an authorization from you in many instances before disclosing
the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition;
before disclosing information about drug or alcohol treatment you have received in a drug or
alcohol treatment program; before disclosing information about mental health services you may
have received. For full information on when such authorizations may be necessary, you can
contact the Privacy Officer.

RIGHTS THAT YOU HAVE
Access to Your Personal Health Information. You have the right to copy and/or inspect much
of the personal health information that we retain on your behalf. All requests for access must be
made in writing and signed by you or your representative. We will charge you a fee if you request
a copy of the information. We will also charge for postage if you request a mailed copy and will
charge for preparing a summary of the requested information if you request such summary. You
may obtain an access request form, including fees, from Health Information Resources.

Amendments to Your Personal Health Information. You have the right to request in writing that
personal health information that we maintain about you be amended or corrected. We are not
obligated to make all requested amendments but will give each request careful consideration. All
amendment requests, in order to be considered by us, must be in writing, signed by you or your
representative, and must state the reasons for the amendment/correction request. If an
amendment or correction you request is made by us, we may also notify others who work with us
and have copies of the uncorrected record if we believe that such notification is necessary. You
may obtain an amendment request form from Health Information Resources.

Accounting for Disclosures of Your Personal Health Information. You have the right to
receive an accounting of certain disclosures made by us of your personal health information after
April 14, 2003. Requests must be made in writing and signed by you or your representative.
Accounting request forms are available from Health Information Resources. The first accounting
in any 12-month period is free; you will be charged a fee of $50.00 for each subsequent
accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Personal Health Information. You have the right
to request restrictions on certain of our uses and disclosures of your personal health information
for treatment, payment, or health care operations. A restriction request form can be obtained
from Health Information Resources. We are not required to agree to your restriction request but
will attempt to accommodate reasonable requests when appropriate and we retain the right to
terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a
termination by us, we will notify you of such termination. You also have the right to terminate, in
writing or orally, any agreed-to restriction by sending such termination notice to Health
Information Resources.

Complaints. If you believe your privacy rights have been violated, you can file a written complaint
with the Patient Advocate, Knox Community Hospital, 1330 Coshocton Avenue, Mount Vernon,
OH 43050. You may also file a complaint with the Secretary of the U.S. Department of Health and
Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There
will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Notice. You will be asked to sign an acknowledgment form that
you received this Notice of Practice Practices.

For Further Information
If you have questions or need further assistance regarding this Notice, you may contact:

Privacy Officer
Knox Community Hospital
1330 Coshocton Avenue
Mount Vernon, OH 43050
740-393-9888
Privacy.Officer@KnoxCommHosp.org

As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if
you have requested such copy by e-mail or other electronic means.

Effective Date
This Notice of Privacy Practices is effective April 14, 2003.
Community Pediatrics      1320 Coshocton Road, Suite F      Mount Vernon, Ohio 43050       (740) 393-9111
charles.bell@knoxcommhosp.org
Community Pediatrics
Privacy Notice