                                                     NOTICE OF PRIVACY PRACTICES
                                                                                          Effective April 14, 2003
     THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
                 DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
                                     PLEASE READ THIS NOTICE CAREFULLY.
At the Cleveland Clinic Health System, we believe that your health information is personal. We keep
records of the care and services that you receive at our facilities. We are committed to keeping your
health information private, and we are also required by law to respect your confidentiality.
This Notice describes the privacy practices of the Cleveland Clinic Health System and its affiliated
facilities (CCHS). This Notice applies to all of the health records that identify you and the care you
receive at CCHS facilities. If you are under 18 years of age, your parents or guardian must sign for you
and handle your privacy rights for you. We are legally required to give you this Notice and to follow the
terms of the Notice that is currently in effect.
CLEVELAND CLINIC HEALTH SYSTEM AND AFFILIATED FACILITIES
All of our hospitals, employed physicians, doctor offices, entities, foundations, facilities, home care
programs, other services, and affiliated facilities follow the terms of this Notice. These hospitals and
locations are shown at the end of this Notice.
The doctors and other caregivers at CCHS who are not employed by CCHS exchange information about
you as a patient with CCHS employees. These health care practitioners may also give you other privacy
notices that describe their office practices.
All of these hospitals, doctors, entities, foundations, facilities, and services may share your health
information with each other for reasons of treatment, payment, and health care operations as discussed
below.
HOW CCHS MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
When you become a patient of CCHS, we will use your health information within CCHS and disclose your
health information outside CCHS for the reasons described in this Notice. The following categories
describe some of the ways that we will use and disclose your health information.
Treatment. We use your health information to provide you with health care services. We may disclose
your health information to doctors, nurses, technicians, medical or nursing students, or other persons at
CCHS who need that information to take care of you. For example, a doctor treating you for a broken leg
may need to ask another doctor if you have diabetes because diabetes may slow the leg’s healing
process. This may involve talking to doctors and others not employed by us. We also may disclose your
health information to people outside CCHS who may be involved in your health care, such as treating
doctors, home care providers, pharmacies, drug or medical device experts, and family members.
Payment. We may use and disclose your health information so that the health care you receive may be
billed and paid for by you, your insurance company, or another third party. For example, we may give
information about surgery you had here to your health plan so it will pay us or reimburse you for the
© Cleveland Clinic Health System 2002                                             CCHS PRIVACY FORM PF-204.2—1


                                                     NOTICE OF PRIVACY PRACTICES
                                                                                        Effective April 14, 2003
surgery. We may also tell your health plan about a treatment you are going to receive so we can get prior
payment approval or learn if your plan will pay for the treatment.
Health Care Operations. We may use your health information and disclose it outside CCHS for our
health care operations. These uses and disclosures help us operate CCHS to maintain and improve
patient care. For example, we may use your health information to review the care you received and to
evaluate the performance of our staff in caring for you. We also may combine health information about
many patients to identify new services to offer, what services are not needed, and whether certain
therapies are effective. We may also disclose information to doctors, nurses, technicians, medical
students, and other persons at CCHS for learning and quality improvement purposes. We may remove
information that identifies you so people outside CCHS may study your health data without knowing who
you are.
Contacting You. We may use and disclose health information to reach you about appointments and
other matters. We may contact you by mail, telephone or email. We may leave voice messages at the
telephone number you provide us with, and we may respond to your email address.
Health-Related Services. We may use and disclose health information about you to send you mailings
about health-related products and services available at CCHS.
Philanthropic Support. We may use general demographic information about you to contact you in an
effort to raise funds to support CCHS and its operations. We also will tell you how to cancel these
communications.
Patient Information. Our hospitals include limited information about you in their patient directories, such
as your name and possibly your location in the hospital and your general condition (for example: good,
fair, serious, critical, or undetermined). We usually give this information to people who ask for you by
name. We also may include your religious affiliation in the directories and give your name to members of
the clergy. We do not release this information if you are being treated on a psychiatric or substance
abuse unit. Releasing directory information about you enables your family and others (such as friends,
clergy, and delivery persons) to visit you in the hospital and generally know how you are doing. We will
not release any of this information if you tell the hospital’s admitting department not to.
Medical Research. We perform medical research here. Our clinical researchers may look at your health
records as part of your current care, or to prepare or perform research. They may share your health
information with other CCHS researchers. All patient research conducted at CCHS goes through a
special process required by law that reviews protections for patients involved in research, including
privacy. We will not use your health information or disclose it outside CCHS for research reasons without
either getting your prior written approval or determining that your privacy is protected.
Organ and Tissue Donation. We may release health information about organ, tissue, and eye donors
and transplant recipients to organizations that manage organ, tissue, and eye donation and
transplantation.
Legal Matters. We will disclose health information about you outside CCHS when required to do so by
federal, state, or local law, or by the court process. We may disclose health information about you for
public health reasons, like reporting births, deaths, child abuse or neglect, reactions to medications or
problems with medical products. We may release health information to help control the spread of disease
or to notify a person whose health or safety may be threatened. We may disclose health information to a
health oversight agency for activities authorized by law, such as for audits, investigations, inspections,
and licensure.
© Cleveland Clinic Health System 2002                                           CCHS PRIVACY FORM PF-204.2—2


                                                    NOTICE OF PRIVACY PRACTICES
                                                                                        Effective April 14, 2003
AUTHORIZATIONS FOR OTHER USES AND DISCLOSURES
As described above, we will use your health information and disclose it outside CCHS for treatment,
payment, health care operations, and when permitted or required by law. We will not use or disclose your
health information for other reasons without your written authorization. For example, you may want us to
release medical information to your employer or to your child’s school. These kinds of uses and
disclosures of your health information will be made only with your written authorization. You may revoke
the authorization, in writing, at any time, but we cannot take back any uses or disclosures of your health
information already made with your authorization.
YOUR RIGHTS REGARDING HEALTH INFORMATION
Right to Accounting. You may request an accounting, which is a listing of the entities or persons (other
than yourself) to whom CCHS has disclosed your health information without your written authorization.
The accounting would not include disclosures for treatment, payment, health care operations, and certain
other disclosures exempted by law. Your request for an accounting of disclosures must be in writing,
signed, and dated. It must identify the time period of the disclosures and the CCHS facility that maintains
the records about which you want the accounting. We will not list disclosures made before April 14, 2003,
or those made earlier than 6 years before your request. Your request should indicate the form in which
you want the list (for example, on paper or electronically). You must submit your written request to the
medical records department of the CCHS hospital or facility that maintains the records or to the Privacy
Office, The Cleveland Clinic Foundation, Cleveland, Ohio 44195. We will respond to you within 60 days.
We will give you the first listing within any 12-month period free, but we will charge you for all other
accountings requested within the same 12 months.
Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you
have the right to ask us to amend your medical records. Your request for an amendment must be in
writing, signed, and dated. It must specify the records you wish to amend, identify the CCHS facility that
maintains those records, and give the reason for your request. You must address your request to the
Privacy Official of the CCHS hospital or facility that maintains the records you wish to amend or to the
Privacy Office, The Cleveland Clinic Foundation, Cleveland, Ohio 44195. CCHS will respond to you
within 60 days. We may deny your request; if we do, we will tell you why and explain your options.
Right to Inspect and Obtain Copy. You have the right to inspect and obtain a copy of your completed
health records unless your doctor believes that disclosure of that information to you could harm you. You
may not see or get a copy of information gathered for a legal proceeding or certain research records while
the research is ongoing. Your request to inspect or obtain a copy of the records must be submitted in
writing, signed and dated, to the medical records department of the CCHS hospital or facility that
maintains the records. (Requests for billing records should be sent to the billing departments.) We may
charge a fee for processing your request. If CCHS denies your request to inspect or obtain a copy of the
records, you may appeal the denial within CCHS.
Right to Request Restrictions. You have the right to ask us to restrict the uses or disclosures we make
of your health information for treatment, payment, or health care operations, but we do not have to agree.
You also may ask us to limit the health information that we use or disclose about you to someone who is
involved in your care or the payment for your care, like a family member or friend. Again, we do not have
to agree. A request for a restriction must be signed and dated, and you must identify the CCHS hospital
or facility that maintains the information. The request should also describe the information you want
restricted, say whether you want to limit the use or the disclosure of the information or both, and tell us
who should not receive the restricted information. You must submit your request in writing to the medical
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                                                               NOTICE OF PRIVACY PRACTICES
                                                                                                       Effective April 14, 2003
records department of the CCHS hospital or facility that maintains the information you want restricted or
to the Privacy Office, The Cleveland Clinic Foundation, Cleveland, Ohio 44195. We will tell you if we
agree with your request or not. If we do agree, we will comply with your request unless the information is
needed to provide you with emergency treatment.
Right to Request Confidential Communications. You have the right to request that we communicate
with you about your health in a certain way or at a certain location. For example, you can ask that we
only contact you at work or by mail. Your request for confidential communications must be in writing,
signed, and dated. It must identify the CCHS hospital or facility making the confidential communications
and specify how or where you wish to be contacted. You need not tell us the reason for your request,
and we will not ask. You must send your written request to the medical records department of the CCHS
hospital or facility making the confidential communications or to the Privacy Office, The Cleveland Clinic
Foundation, Cleveland, Ohio 44195. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask
us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice
electronically, you are still entitled to a paper copy of this Notice. You may obtain a paper copy of this
Notice at any of our facilities or by calling the CCHS Privacy Office at 216/444-1709. You may view this
Notice at our Web site, www.cchs.net.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with CCHS or with the
Secretary of the U.S. Department of Health and Human Services. To file a complaint with CCHS, you
must submit your complaint in writing to the Privacy Office, The Cleveland Clinic Foundation, Cleveland,
Ohio 44195. You will not be penalized for filing a complaint.
CHANGES TO THIS NOTICE
CCHS may change this Notice at any time. Any change in the Notice could apply to medical information
we already have about you, as well as any information we receive in the future. We will post a copy of
the current Notice at each of our facilities and on our Web site, www.cchs.net. The effective date of the
Notice is on the first page in the top right corner.
                                                      If you have questions about this Notice, you may telephone
                           the number shown below for your CCHS facility and ask for the privacy official.
            You may also call the Privacy Office of the Cleveland Clinic Health System at 216/444-1709.
CLEVELAND CLINIC HEALTH SYSTEM AND AFFILIATED FACILITIES (and telephone numbers of privacy officials)
• Cleveland Clinic Main Campus in Cleveland, Ohio (216/444-1709)
• Cleveland Clinic Northern Ohio Regional Health Centers, including Centers in Beachwood, Brunswick, Chagrin Falls, Creston,
      Elyria, Independence, Lakewood, Lorain, Solon, Strongsville, Westlake, Willoughby Hills, and Wooster (216/444-1709)
• Euclid, Hillcrest, Huron, and South Pointe Hospitals in Northeast Ohio (216/430-8228)
• Fairview, Lutheran, and Lakewood Hospitals in Northeast Ohio (216/476-7280)
• Marymount Hospital in Northeast Ohio (216/587-8226)
• Cleveland Clinic Florida: Weston—Clinic only (954/659-5000); Naples—Clinic and Hospital (239-348-4000)
• Cleveland Clinic Children’s Hospital for Rehabilitation in Northeast Ohio (216/721-5400)
• Cleveland Clinic Home Care Services (216/520-1998)
Affiliated Facilities
• Ashtabula Medical Center, Glenbeigh Hospital and Outpatient Centers, Ashtabula Regional Home Health, and Hospice of
      Ashtabula County, Ohio (440/997-6502)
© Cleveland Clinic Health System 2002                                                           CCHS PRIVACY FORM PF-204.2—4
