Effective September 23, 2013



This notice describes the ways in which Meeker Memorial Hospital & Clinics may use and disclose Protected Health Information (PHI) about you.  This notice describes your rights and certain obligations we have regarding the use and disclosure of PHI.  Under the Health Insurance Portability and Accountability Act (HIPAA), Protected Health Information is defined as:  Information about 1) your physical/mental health or condition, any healthcare provided to you, or payment of health care provided to you whether past, present or future, 2) that is created by us, and 3) that identifies you or could be used to identify you.

We understand that information about you and your health is personal.  We are committed to protecting the privacy of your PHI.  We create a record of the care and services you received to provide you with quality care and to comply with legal requirements.  This Notice of Privacy Practices (Notice) applies to all of your PHI generated by the hospital, whether made by hospital staff or your personal doctor.  Your personal doctor may have different policies or notices regarding the use and disclosure of you PHI created in the doctor’s office or clinic.

We Are Required by Law To:

  • Make sure that PHI that identifies you is kept private.
  • Give you a notice of our legal duties and privacy practices with respect to PHI about you.
  • Make good faith efforts to obtain written acknowledgement of receipt of this Notice from you; maintain records of the signed receipts, and document the failure to obtain a receipt.
  • Follow the terms of this Notice that is currently in effect.
  • Change the Notice in accordance with Federal and State regulations and to suite our facility’s administrative needs.
  • Provide our internal complaint process for privacy issues to you.
  • Notify you following a breach of unsecure PHI; and
  • Make the notice of any revised Notice available in hard copy, by posting it in our facility, and displaying it on our web site. You can request a Notice in person or my mail.


  • Any health care professionals authorized to enter information into your medical and billing records;
  • All medical students and other trainees affiliated with the hospital.
  • Any member of the Volunteer/Auxiliary that may help you while you are in the hospital.
  • All departments, units, employees, staff and other hospital personnel.
  • All credentialed medical staff including physicians and other allied health professionals. All entities that provide a service to the hospital under contractual agreements.  In addition, these medical staff, entities, sites and locations may share PHI with each other for treatment, payment or hospital operations purposes described in this Notice.


The following categories describe different ways we use and disclose PHI.  For each category of uses or disclosure, we will explain what we mean and try to give some examples.  However, not every possible use or disclosure in a category will be listed.  We will not use or disclose PHI except as described in the Notice or allowed by law without your written authorization for such use or disclose of your PHI.

  • For Treatment: We will use PHI about you to provide you with medical treatment or services.  We may disclose PHI about you to doctors, nurses, technicians, medical students or other hospital personnel who are involved in taking care of you at the hospital.  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 meals.  We also may disclose PHI about you to people outside the hospital who may be involved in or have information necessary for you medical care.
  • For Payment: We may use and disclose PHI about you so that the treatment and services you receive at the hospital may be billed 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 surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether you plan will cover the treatment.
  • For Health Care Operations: We may use and disclose PHI about you for hospital operations.  These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care.  For example, we may use PHI to review your treatment and services and to evaluate the performance of our staff in caring for you.  We may also disclose information to doctors, nurses, technicians, medical students and other hospital personnel for review and learning purposes.  We may also combine the PHI we have with PHI from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer.  We may remove information that identifies you from this set of PHI so others may use it to study health care and health care delivery without learning who the specific patients are.
  • Business Associates: Some health care administration and operation activities are performed for us by our business associates.  Examples of our business associates include our claims administrator, transcription service or shredding service.  We may disclose your PHI to our business associates so they can perform the job we have asked them to do.  We require our business associates to appropriately safeguard PHI to follow our privacy practices.
  • Medical Emergencies: We may use or disclose PHI to help you in a medical emergency.
  • Appointment Reminders: We may use and disclose PHI to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.
  • Treatment Alternatives: We may use and disclose PHI 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 disclosed PHI to tell you about health-related benefits or services that may be of interest to you.
  • Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital, unless you tell us not to do so.  This information may include your name, location in the hospital, your general condition (example fair, stable, etc.) and your religious affiliation.  The directory information, except for you religious affiliation, may also be released to people who ask for you by name.  Your religious affiliation may be given to a member of the clergy, even if they don’t ask for you by name.  This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.
  • Individuals Involved in Your Care or Payment for Your Care: We may release PHI about you to a friend or family member who is involved in your medical care.  We may also give information to someone who helps pay for your care.  In addition, we may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  • As Required By Law: We will disclose PHI about you when required to do so by Federal, State or local law.  When the disclosure of PHI is prohibited or restricted by applicable law, the hospital’s disclosure will reflect the more stringent law.
  • To Avert a Serious Threat to Health or Safety: We may use and disclose PHI 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.
  • Research: We may use and disclose PHI about you under certain circumstances, such as a chart review to compare outcomes of patients who received different types of treatments.  On occasion, researchers contact patients regarding their interest in certain research studies.  We will ask for you 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.  Enrollment in these studies can only occur after you have been informed about the study; had an opportunity to ask questions and indicated your willingness to participate by signing a consent form.
  • Support of Fundraising Efforts: We would only use information such as your name, address, phone number, age, gender, date of birth and the dates you received treatment, treating physician, outcome information, department of service information, and health insurance status.  You have the right to opt out of receiving such communications by contacting the Privacy Officer at the phone number on this notice.  Opting out will have no impact on your treatment or payment for your treatment.
  • Pursuant to Your Written Authorization: We may use and disclose your PHI pursuant to your written authorization.  MMH has authorization forms available.  A completed form must state the parties to whom the information is to be disclosed, which PHI is to be disclosed, and the duration/purpose of the authorization.


  • Organ and Tissue Donation: If you are an organ donor, we may release PHI 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 PHI about you as required by military command authorities.  We may also release PHI about foreign military personnel to the appropriate foreign military authority.
  • Worker’s Compensation: We may release PHI about you for worker’s compensation or similar programs as authorized or require by law.  These programs provide benefits for work-related injuries or illnesses.
  • Public Health Risks: We may disclose PHI about you for public health activities.  These activities may include:
    • To prevent or control disease, injury or disability.
    • To report births and deaths.
    • To report reactions to medications or problems with products.
    • To notify people of recalls of products they may be using.
    • To make other reports as request by law.
    • To notify people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • Abuse: We may give PHI to the proper government authorities if we believe a patient has been the victim of abuse, neglect or domestic violence.
  • Health Oversight Activities: We may disclose PHI 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.
  • Legal Process: If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order.  We may also disclose PHI about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.
  • Law Enforcement: We may release PHI to law enforcement.  This could be;
    • In response to a court order, subpoena, warrant, summons or similar process.
    • 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 occurring on our premises and,
    • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
  • Coroners, Medical Examiners and Funeral Directors: We may release PHI 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 PHI about patients of the hospital to funeral directors as necessary to carry out their duties.
  • National Security and Intelligence Activities:  We may release PHI about you to authorized federal officials or foreign heads of state for intelligence, counterintelligence, special investigations or other national security authorized by law.
  • Correctional Facility: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official as authorized by law.


Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written permission:  Other uses may include:

  • Most uses and disclosures of psychotherapy notes collected by a psychotherapist during a counseling session;
  • Uses and disclosure of your information for most marketing purposes;
  • Sale of your information; and,
  • Any other situation not covered by this Notice.

If you provide us permission to use or disclose PHI about you, you may revoke that 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.


You have the following rights regarding the PHI we maintain about you:

  • Inspect and Copy Your Health Information: In most cases, you have the right to inspect and obtain a copy of your health care information when you submit a written request.  You have the right to request that the copy be provided in an electronic form or format.  (e.g. PDF saved onto a CD) If the form and format are not readily producible, then the organization will work with you to provide it in a reasonable electronic form or format.  Written requests should be sent to “Meeker Memorial Hospital & Clinics Release of Information.” If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associates with your request.  If we deny your request to obtain a copy, you may submit a written request for a review of that decision.
  • Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing that provides your reason for requesting the amendment.  We may deny your request for an amendment if the information was not created by us, if it is not part of the medical information maintained by us or if we determine that the record is accurate.  You may appeal, in writing, a decision by us not to amend a record.
  • Right to an Accounting of Disclosures: You have the right to request a list of the disclosures we made of your PHI except for uses and disclosures made for treatment, payment and health care operations if you submit a written request.  Your request must state a time period desired for the account which may not be longer than six years and may not include dates before April 14, 2003.  The first list you request within a 12 month period will be free.  For additional lists, we may change you for the cost of copying, mailing or other supplies associates with your request.  We will inform you of the fee before you incur any costs.
  • Right to Request Restrictions: You may request, in writing, a restriction or limitation on the PHI we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a surgery you had to a specific family member.  We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatments.
  • In your request you must tell us, 1) what information you want to limit, and 2) to whom you want the limits to apply. We will honor a request to restrict disclosure for you information to a health plan if:
  • The disclosure is for the propose of caring out payment or health care operations and is not otherwise require by law, AND
  • The information pertains solely to a health care item or service for which you, or someone on your behalf (other than your health plan), has paid us in full.
  • Right to Request Confidential/Alternative Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, by notifying us in writing.  For example you can ask that we only contact you at work or by mail. 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.  Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy.  You may obtain a copy of this Notice at our website,  To obtain a paper copy of this Notice, go to the hospital registration area or contact the MMHC Privacy Officer.


We reserve the right to change the Notice and make the revised Notice effective for PHI we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice in the hospital and on the MMHC website: and will promptly make any revision available upon request.  The Notice will contain the effective date.  Meeker Memorial Hospital & Clinics also reserves the right to change its policies, procedures and practices in response to changes in the law or regulations and to suite its administrative needs.


If you have questions or concerns regarding our privacy practices please contact the MMHC Privacy Officer at the address provided below.  If you believe your privacy rights have been violated, you may file a written complaint with the hospital.  To file a complaint with the hospital, contact the MMH Privacy Officer.  All complaints must be submitted in writing.  Finally, you may send a written compliant to the Secretary of the Department of Health and Human Services (DHHS).  We will provide you with the DHHS contact information upon request.  We support your right to the privacy of your PHI and will not retaliate in any way if you choose to file a complete with us or with the DHHS.

Please address all written correspondence to:

Meeker Memorial Hospital & Clinics Privacy Officer
612 S. Sibley Avenue
Litchfield, MN  55355




Meeker Memorial Hospital & Clinics embraces a philosophy of open and flexible visitation and that welcomes and encourages the involvement of family and significant others in the patient’s care.  Accordingly, Meeker Memorial Hospital & Clinics has adopted this statement on Patients’ Visitation Rights.

  • Patients may receive visitors of their choosing including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member or a friend.
  • Patients may refuse to consent to a person visiting them or may withdraw consent to see a visitor at any time.  For assistance with process, please contact your nurse.
  • Meeker Memorial Hospital & Clinics will make all reasonable efforts to ensure that visitors enjoy full and equal visitation privileges consistent with patient preferences.  Meeker Memorial Hospital & Clinics will not restrict, limit or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.
  • Patients may designate a “Support Person” to express their visitation preferences on their behalf.  Patients may designate a Support Person in any manner, including orally, in writing or through non-verbal communications (such as pointing).
  • Meeker Memorial Hospital & Clinics may apply reasonable clinical and other restrictions on patient visitation.  Reasonable restrictions may be based upon, but are not limited, any of the following:
    1. A court order limiting or restraining contact.
    2. A visitor’s behavior presenting a risk to the patient, Meeker Memorial Hospital & Clinics staff or others in the immediate environment.
    3. Visitor behavior that is disruptive to the functioning of the patient care unit involved
    4. The patient’s risk of infection by the visitor.
    5. The visitor’s risk of infection by the patient.
    6. A patient’s need for privacy or rest.
    7. Any special restriction rules that apply to special patient care units (Behavioral Health, Newborn Nursery, Critical Care, etc).
    8. When visitation would otherwise interfere with the care of the patient and/or the care of the other patients.
    9. A patient is undergoing care interventions (however, Meeker Memorial Hospital & Clinics will try to accommodate the needs of any patient who requests that at least one visitor be allowed to remain in the room to provide support and comfort at such times).



As a patient, you have the right to make your own informed decisions about medical care and to communicate these decisions to healthcare providers. If, however, through sickness or injury you

become unable to make informed decisions about your medical care, including whether to accept or refuse treatment, how will your healthcare providers and family know your wishes?

An advance directive (may be called a “health care directive”) is a legal document that allows you to state your choices for medical treatment before you actually need such care. When you need medical care, certain decisions need to be made involving the kind of care to be given. These decisions may become harder if you become unable to tell your doctor and loved ones what kind of medical care you want. Taking the time to fill out an advance directive also gives you the opportunity to tell healthcare providers what your wishes are regarding your treatment and allows you to name a person to make treatment decisions for you in the event that you are unable to speak for yourself. A signed advance directive will only be followed in the event that you become mentally or physically unable to convey your wishes regarding medical care decisions.


Minnesota Law

Minnesota law allows you to inform others of your health care wishes. You have the right to state your wishes or appoint an agent in writing so that others will know what you want if you can’t tell them because of illness or injury. The information that follows tells about health care directives and how to prepare them. It does not give every detail of the law.

What is a Health Care Directive?

A health care directive is a written document that informs others of your wishes about your health care. It allows you to name a person (“agent”) to decide for you if you are unable to decide. It also allows you to name an agent if you want someone else to decide for you. You must be at least 18 years old to make a health care directive.

Why Have a Health Care Directive?

A health care directive is important if your attending physician determines you can’t communicate your health care choices (because of physical or mental incapacity). It is also important if you wish to have someone else make your health care decisions. In some circumstances, your directive may state that you want someone other than an attending physician to decide when you cannot make your own decisions.

Must I Have a Health Care Directive?   What Happens if I Don’t Have One?

You don’t have to have a health care directive. But, writing one helps to make sure your wishes are followed.

You will still receive medical treatment if you don’t have a written directive. Health care providers will listen to what people close to you say about your treatment preferences, but the best way to be sure your wishes are followed is to have a health care directive.

What is Meeker Memorial Hospital & Clinics policy for Health Care Directives?

Meeker Memorial Hospital & Clinics respects the rights and responsibilities of patients to make choices about their health care, including decisions regarding withholding or withdrawing life-sustaining treatment.

Meeker Memorial Hospital & Clinics is committed to providing you with health care treatment information and listening to your treatment choices. You have the right to accept or refuse any medical treatment.

Meeker Memorial Hospital & Clinics will not discriminate against anyone based on whether or not the person has written a Health care Directive.

Meeker Memorial Hospital & Clinics will honor treatment decisions stated in your Health care Directive, except where we believe it is not medically indicated or unethical to do so. If the hospital or doctor cannot honor your Health care Directive based on the above policies, we will make every effort to transfer you to a facility that will. 

How Do I Make a Health Care Directive?

There are forms for health care directives. You don’t have to use a form, but your health care directive must meet the following requirements to be legal:

  • Be in writing and dated.
  • State your name.
  • Be signed by you, or someone you authorize to sign for you, when you can understand and communicate your health care wishes.
  • Have your signature verified by a notary public or two witnesses.
  • Include the appointment of an agent to make health care decisions for you and/or instructions about the health care choices you wish to make.

Before you prepare or revise your directive, you should discuss your health care wishes with your doctor or other health care provider.

Information about how to obtain forms for preparation of your health care directive can be found in the Resource Section of this document.

I Prepared My Directive in Another State.   Is It Still Good?

Health care directives prepared in other states are legal if they meet the requirements of the other state’s laws or the Minnesota requirements. But requests for assisted suicide will not be followed.

What Can I Put in a Health Care Directive?

You have many choices of what to put in your health care directive. For example, you may include:

  • The person you trust as your agent to make health care decisions for you. You can name alternative agents in case the first agent is unavailable or joint agents.
  • Your goals, values and preferences about health care.
  • The types of medical treatment you would want (or not want).
  • How you want your agent or agents to decide.
  • Where you want to receive care.
  • Instructions about artificial nutrition and hydration.
  • Mental health treatments that use electroshock therapy or neuroleptic medications.
  • Instructions if you are pregnant.
  • Donation of organs, tissues and eyes.
  • Funeral arrangements.
  • Who you would like as your guardian or conservator if there is a court action.

You may be as specific or as general as you wish. You can choose which issues or treatments to deal with in your health care directive.

Are There Any Limits to What I Can Put in My Health Care Directive?

There are some limits about what you can put in your health care directive. For instance:

  • Your agent must be at least 18 years of age.
  • Your agent cannot be your health care provider, unless the health care provider is a family member or you give reasons for the naming of the agent in your directive.
  • You cannot request health care treatment that is outside of reasonable medical practice.
  • You cannot request assisted suicide.

How Long Does a Health Care Directive Last?   Can I Change It?

Your health care directive lasts until you change or cancel it. As long as the changes meet the health care directive requirements listed above, you may cancel your directive by any of the following:

  • A written statement saying you want to cancel it.
  • Destroying it.
  • Telling at least two other people you want to cancel it.
  • Writing a new health care directive.

What If My Health Care Provider Refuses to Follow My Health Care Directive?

Your health care provider generally will follow your health care directive or any instructions from your agent, as long as the health care follows reasonable medical practice. But you or your agent cannot request treatment that will not help you or which the provider cannot provide. If the provider cannot follow your agent’s directions about life-sustaining treatment, the provider must inform the agent. The provider must also document the notice in your medical record. The provider must allow the agency to arrange to transfer you to another provider who will follow the agent’s directions.

What If I’ve Already Prepared a Health Care Document?   Is It Still Good?

Before August 1, 1998, Minnesota law provided for several other types of directives including living wills, durable health care powers of attorney and mental health declarations.

The law changed so people can use one form for all their health care instructions.

Forms created before August 1, 1998, are still legal if they followed the law in effect when written. They are also legal if they meet the requirements of the new law (described above). You may want to review any existing documents to make sure they say what you want and meet all requirements.

What Should I Do With My Health Care Directive After I Have Signed It?

You should inform others of your health care directive and give people copies of it. You may wish to inform family members, your health care agent or agents and your health care providers that you have a health care directive. You should give them a copy. It’s a good idea to review and update your directive as your needs change. Keep it in a safe place where it is easily found.

What if I believe a Health Care Provider Has Not Followed Health Care Directive Requirements?

Complaints of this type can be filed with the Office of Health Facility Complaints at 651-201-4200 (Metro Area) or Toll-free at 1-800-369-7994.

What if I Believe a Health Plan Has Not Followed Health Care Directive Requirements?

Complaints of this type can be filed with the Minnesota Health Information Clearinghouse at 651-201-5178 or Toll-free at 1-800-657-3793.

How to Obtain Additional Information

If you want more information about health care directives, please contact your health care provider, your attorney, or:

Minnesota Board on Aging’s Senior LinkAge Line®

A suggested health care directive form is available on the internet at: or your physician, nurse or registration staff can provide information and sample forms. They can also be downloaded at


Prepared by the Minnesota Department of Health, Division of Facility and Provider Compliance, in fulfillment of Section 1902(a) (58) of the Social Security Act, November 1991.  Revised in December 1995, May 1996, and August 1998.


Updated Tuesday, 28-Nov-10



Effective Date:  6/96

Revised:  8/98, 11/04

02-2000, 3/14, 2/20


MMH Notice of Privacy Practices, Patient Visitation Rights, and Advance Directive Notice form. doc