These notices describe how medical information about you may be used and disclosed and how you can get access to this information, please review it carefully. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of these notices for as long as it is in effect.

If you have any questions regarding these notices, please contact:

Keokuk County Hospital & Clinics
Compliance Officer
23019 Highway 149
Sigourney, IA 52591
Phone (641) 622-1127


We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.


  • Make sure that medical information that identifies you is kept private.
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you.
  • Follow the terms of the notice that is currently in effect.


The following categories describe different ways that we use and disclose medical information, which do not require your written authorization. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories:

  • For treatment, care coordination or quality improvement purposes. We may use medical information about you to provide you with medical treatment or services. Beginning in May 2021, CMS Conditions of Participation (CoP) requires Medicare and Medicaid participating hospitals, including CAHs to send notification to certain providers of a patient’s admission, discharge or transfer. KCHC will send notifications of your inpatient, emergency department, and/or observation admission / registration, transfer, and discharge to:  your established primary care practitioner or group; post-acute care service providers and suppliers with whom you have an established care relationship prior to the admission or to whom you are being transferred or referred; or other practitioners, groups or entities, identified by you as primarily responsible for your care. A doctor at the hospital may share your health information with another doctor inside our hospital, or with a doctor at another hospital, to determine how to diagnose or treat you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate dietary teaching. Different departments of KCHC also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside of KCHC who may be involved in your medical care after you leave our care, such as family members, clergy or others we use to provide services that are part of your care
  • For payment. We may use and disclose medical information about you so that the treatment and services you receive at KCHC may be billed to and payment may be collected from you, an insurance company or a third party. For example we may need to give your health plan information about the services you received while under our care so your health plan will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  • For healthcare operations. We may use and disclose medical information about you for KCHC healthcare operations, such as quality assessment and improvement activities, professional training programs, and legal compliance programs. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. These uses and disclosures are necessary to run KCHC and make sure that all of our patients receive quality care.
  • Business Associates. We may disclose your medical information to third-party business associates that we contract with to perform certain business functions or provide certain business services on our behalf, such as auditing, billing, legal services, etc. For example, we may use another company to perform medical billing services. All of our business associates are required to maintain the privacy and confidentiality of your medical information.  In addition, at the request of your other health care providers or health plan, we may disclose your medical information to their authorized business associates for purposes of performing certain business functions or health care services on their behalf. For example, we may disclose medical information to a business associate of Medicare for purposes of medical necessity review and audit.
  • Appointment reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
  • Treatment alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  • Health-related benefits and services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
  • Fundraising activities. We may use medical information about you to contact you in an effort to raise money for KCHC and its operations. We may disclose patient contact information to a foundation related to KCHC so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number, the dates you received treatment or services, the department which treated you, your treating physician, and your medical outcomes. You have the right to opt-out of receiving fundraising communications. If you do not wish to be contacted for fundraising activities, you may contact our Human Resources Department at 641-622-1153. Any fundraising communication sent to you will let you know how you can opt-out of receiving similar communications in the future, or you may opt-out of receiving fundraising communications by sending your name and address to the foundation related to KCHC, together with a statement that you do not wish to receive fundraising materials or communications from us. Your treatment or payment will not be conditioned on your choice with respect to the receipt of fundraising communications.
  • KCHC directory. We may include certain limited information about you in KCHC directory while you are a patient, unless you object. This information may include your general demographic information such as your age and gender, as well as your diagnosis, general condition, attending physician, the service or services you are receiving, and your religious affiliation. This directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if he or she doesn’t ask for you by name.
  • Individuals involved in your care or payment for your care. We may release medical information about you to a friend or family member who is involved in your medical care, unless you object or the law does not allow it. For example, there is a state law that prohibits us from informing the parents or guardians of a minor that the minor has a venereal disease or has had an abortion. There is also a law with special rules for disclosing HIV and AIDS-related information. We may also give information to someone who helps pay for your care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  • Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose medical information for most types of research, the project must be approved through a research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave KCHC. We also may contact you about possible research opportunities. Except in certain very limited circumstances such as described above, we will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.
  • As required by law. We will disclose medical information about you when required to do so by federal, state, or local law.
  • To avert a serious threat to health or safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. An example of a serious threat is a serious and  contagious disease.


  • Involuntary patients. Information regarding patients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payors and others, as necessary to provide the care and management coordination needed in compliance with state and federal law.
  • Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you.
  • Communication Barriers. We may use and disclose your health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.
  • Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
  • Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  • Workers’ compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illnesses.
  • Public health risks. We may disclose medical information about you for public health activities. These activities generally include the following:
  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report child abuse or neglect;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
  • To notify appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
  • Health Regulatory Agencies. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
  • Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
  • Law enforcement. We may release medical information if asked to do so by a law enforcement official:
  • In response to a court order, subpoena, warrant, summons or similar.
  • To identify or locate a suspect, fugitive, material witness, or missing person.
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
  • About a death we believe may be the result of criminal conduct.
  • About criminal conduct at the hospital. In emergency circumstances to report a crime; the location of the crime or victim; or the identity, description or location of the person who committed the crime.
  • Coroners, medical examiners, and funeral directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
  • National security and intelligence activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
  • Protective services for the President and others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
  • Inmates – information released to correctional institution. If you are an inmate of correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.


Marketing. Your written authorization is required for us to use or disclose your medical information for marketing purposes, except if we communicate personally with you face-to-face or if we provide you with prescription refill reminders or otherwise communicate with you about a drug or biologic that you are currently prescribed and we do not in exchange receive any payment that is unreasonably related to our cost of making such communication to you. It is not considered marketing, and therefore your written authorization is not required, if we communicate with you related to your individual treatment, case management, or care coordination, or if we direct or recommend alternative treatment, therapies, healthcare providers or settings of care, unless we receive payment from a third-party in exchange for making such communication to you. If marketing activities are to result in payment to us from a third party we will state this on the authorization.

Media consent. Authorization for Use of photographs, audio and/or video recordings, prepared statements, testimonials and interviews for Marketing and Communications require signed authorization. Before circulating any material with your picture, name, signature, voluntary statement, testimonial or any other information specific to you, we will request authorized permission from you or your legal representative. Photographs, audio and/or video recordings, prepared statements, testimonials and interviews may be used for single or multiple purposes in any print publication or electronic media (including but not limited to newspapers, advertising, television, social media, radio, magazines, brochures and websites) as approved by Keokuk County Hospital & Clinics (KCHC). This includes publications and electronic materials prepared by KCHC as well as outside organizations. If the organization authorized to receive any material is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. Images and data could be captured or used by a third party without the permission of KCHC. Should this occur, consent will waive any claims against KCHC for any such unauthorized use. Consent waives the right to inspect or approve any images prior to any form of usage. Images may be modified to be used as design elements. Consent releases all rights to any media, as specified, to Keokuk County Hospital & Clinics and their marketing affiliates.

Consent may be revoked at any time by providing written notice to Keokuk County Hospital & Clinics, Attn: Marketing, 23019 Highway 149, Sigourney, IA 52591. The revocation will not affect actions taken before the receipt of written notification.

Sale of Medical Information. Your written authorization is required for any use or disclosure which is considered a sale of your medical information. Any authorization for the sale of medical information will state that the disclosure will result in payment to us.

Psychotherapy Notes. Your written authorization is required for any use or disclosure of psychotherapy notes, except: for use by the originator of the psychotherapy notes for treatment or health oversight activities; for use or disclosure for our own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; for use or disclosure to defend us in a legal action or other proceeding brought by you; to the extent required to investigate or determine our compliance with the applicable law; to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law; for health oversight activities with respect to the oversight of the originator of the psychotherapy notes; for disclosure to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or if disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Telehealth Services. For consult-based services that may be provided to me from another location by live video technology (“telehealth”). I understand that I can withdraw this permission at any time by telling my provider when telehealth services are recommended to me and that if I choose to withdraw this permission, there may be certain services that I am not able to receive at a KCHC. You may refuse telehealth services at any time without affecting your right to future care or treatment and without risking any third party payor benefits to which you are entitled. You will have the right to access the medical record of the telehealth services as provided by law; PHI will be subject to sharing, storage, and retention of identifiable images or other information from the telehealth service, with the understanding that like in-person care, any identifiable images or other
information will not be shared except as required or permitted by law.


You have the following rights regarding medical information we maintain about you:

Right to inspect and copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to KCHC’s Health Information Management. If you request a copy of the information, we will act on your request within 30 days, unless we need an extension of that time. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by KCHC will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to amend. You have the right to request an amendment of your health information for as long as the information is kept by or for KCHC. Your amendment request must be made in writing and submitted to the Health Information Management department. We may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for KCHC;
  • Is not part of the information which you would be permitted to inspect and copy;
  • or
  • Is accurate and complete.

Right to accounting of disclosures. You have the right to request an accounting, or list, of certain disclosures we have made of your information within the last 6 years. To request this list or accounting of disclosures, you must submit your request in writing to KCHC’s Health Information Management Department. Your request must state a time period, which may not be longer than six years and may not include dates prior to April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We must act on you your request within 60 days of when we receive it, but we can request an extension of time if we tell you the reason for the delay.

Right to request restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you for purposes of maintaining an KCHC directory. For example, you could ask that we not use or disclose information about your location in the hospital or your religious affiliation. We are required to comply with a request that we not disclose your health information to a health plan for payment or health care operations purposes, if the health information pertains to a health care item or service for which we have been involved and you have paid for the item or service in full out-of-pocket. For all other requests, we will consider your requested restriction but WE ARE NOT REQUIRED TO AGREE WITH YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to KCHC’s Health Information Management. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to KCHC’s Health Information Management Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify
how or where you wish to be contacted.

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. You may obtain a copy by clicking on one of these this links: PRIVACY POLICIES or PRACTICAS DE PRIVACIDAS.


We will notify you in writing if we discover a breach of your unsecured health information, unless we determine, based on a risk assessment, that notification is not required by applicable law. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what has been done or can be done to mitigate any harm to you as a result of such breach.


We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for 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 within KCHC. The notice will contain on the first page, in the top right hand corner, the effective date. The next time you come to KCHC to receive treatment, you can ask for a copy of the current notice in effect.


If you believe your privacy rights have been violated, you may file a complaint with KCHC by contacting the Compliance Officer at 641-622-1127; or placing your complaint in writing to the Department of Health and Human Services. We will not retaliate against you for filing a complaint.


Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. You may revoke this written permission, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Effective Date. This notice will become effective on September 1, 2013. Please note, we reserve the right to revise this notice at any time. When we make an important change to our policies, we will change this notice and post a new notice on our Website (https://www.keokukhealth.com). A current notice of our privacy practices may be obtained from the Business Office. You may also request a copy of our current notice at any time from the business office.


This notice has been provided to you as a summary of how we will use your protected health information (PHI) and your rights with respect to your protected information. If you have any questions or for more information regarding your protected health information (PHI), please contact our (HIM) Health Information Management Department at 641-622-1150