Privacy Policy


This policy applies to all Community Health Network (CHNw) workforce members who register or check patients in for health care services.


The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires us to provide a notice of privacy practices. The notice describes how we will use and disclose a person’s protected health information (PHI) in compliance with HIPAA.


A. An individual (usually a patient) has the right to notice

  1. The uses, disclosures or releases CHNw may make of his or her PHI;
  2. The patient’s rights; and
  3. CHNw’s legal duties.

B. CHNw’s written Notice of Privacy Practices (Privacy Notice) describes how CHNw may use and disclose a patient’s PHI.

C. All patients will be given the Privacy Notice the first time the patient gets services or treatment at any CHNw facility or office.

D. The Privacy Notice is on the website,

E. The Privacy Notice and any revisions will be posted and easy to access in prominent places, such as patient registration and check-in, and available in hard copy.

F. An employee will make a reasonable good faith effort to get a patient’s written confirmation of receipt of the Privacy notice. If the employee is not able, they will document their effort including the reason they could not obtain the confirmation.

G. In an emergency, the patient should receive the Privacy Notice as soon as reasonably possible.

H. Employees responsible for giving Privacy Notices to patients must understand it and be able to explain it to patients and others.


A. Confirmation is a patient’s acknowledgement that he or she received a Privacy Notice.

B. Protected Health Information (PHI) is “individually identifiable health information” that:

  1. identify the patient; or
  2. there is a reasonable basis to believe can be used to identify the patient.




A. All departments, clinics and physician practices that register or receive patients for services will maintain a supply of the current “Community Health Network, Inc. Notice of Privacy Practices.”

B. Copies of the Privacy Notice are ordered through the CHNw Forms Vendor or printed from eForms on inComm.

C. Give the patient a copy of the Privacy Notice at the first service. NOTE: Making the Privacy Notice available, or giving the patient a Privacy Notice only if he or she asks for a copy, does not meet this requirement.

D. Ask the patient to initial the Patient Consent Agreement to confirm receipt of the Privacy Notice.

E. If you cannot obtain the patient’s confirmation, write a brief statement that describes your good faith effort and explains why you could not obtain the confirmation.

F. Answer any questions about the Privacy Notice.

G. The Privacy Notice describes the rights to:

  1. access,
  2. accounting of disclosures,
  3. amendment,
  4. confidential communications,
  5. request restrictions, or
  6. revoke an authorization

H. If the patient wants to exercise any of those rights, get help from a supervisor or refer the patient to the appropriate contact person.

  1. If you cannot answer the patient’s questions about the Privacy Notice, involve a supervisor or leader.
  2. If the patient still has questions, contact a compliance liaison (see the Compliance Liaisons Contact Information on inComm>Departments>Compliance and Privacy) or the VP Compliance.

I. Process for Persons not Registered in Epic

  1. Give a copy of the Privacy Notice to persons who are not registered in Epic, but with whom CHNw has a direct treatment relationship, such as health screening participants.
  2. This can be done via electronic “pop-up” window, e-mail, U.S. Mail delivered to the person’s home, or other reasonable method.
  3. Get the person’s written confirmation of receipt of the Privacy Notice.
  4. Document the method of delivery and your reasonable efforts to get the person’s written confirmation
    of receipt.

J. Maintain all documentation for six (6) years.






Health Insurance Portability and Accountability Act, 45 CFR § 164.520


Community Health Network Notice of Privacy Practices (Form #16126)

Notice of Privacy Practices Contact List (maintained on InComm>Departments>Compliance and

Privacy and Confidentiality of Protected Health Information

Network Responsibility and Compliance Program (NRCP)



No Attachments

Approval Signatures

Step Description



Chief Risk and Compliance Officer

Virginia Davidson


Stakeholders (Compliance Collaborators User Group)

Darlene Wilhoit


VP Compliance

Jackie Smith


Policy Owner

Marti Baker



Community Health Network, Inc., Community Health Outpatient, Community Health Retail, Community Hospital East and Heart Hospital, Community Hospital North, Community Hospital South, Community Howard Regional Health, Community Howard Specialty Hospital, Visionary Enterprises, Inc.