Notice of Privacy Practices



This notice describes our hospital and health care center's,Cookeville Regional Medical Center Authority's ("CRMC"), privacy practices and that of specific doctors and health care professionals who participate in an organized health care arrangement ("arrangement") with us to provide an integrated health care setting.

It is important for you to know that most doctors who care for you at CRMC are not employees of the facility, so we must have an arrangement by which doctors and facility employees work together to provide quality patient care. The privacy practices in this notice apply to doctors and other independent health care professionals and only relates to the patient care services provided at CRMC. This notice is meant to satisfy a "joint notice" requirement, so that your health care service at CRMC is not disrupted by each individual caregiver having to provide his or her own notice of privacy practices before caring for you in our facility. Doctors and other independent health care professionals may have different policies or notices regarding their use and disclosure of the medical information created or received by their offices or clinics.

People who work within our arrangement will share protected health information with each other, as necessary to carry out treatment, payment, or health care operations relating to our arrangement.

Therefore, this notice applies to:

  • CRMC, which includes any health care entity legally owned or operated by CRMC.
  • All CRMC employees, volunteers, and students of specific educational programs.
  • Business associates of CRMC, such as businesses, health care professionals and/or employees who are contracted to provide CRMC facility-based services. To protect your information, we require the business associate and their employees to appropriately safeguard your information. Examples: pathology, emergency, information system services, and doctors who are employed to direct certain patient care programs.
  • Any doctor or health care professional who is part of CRMC's organized health care arrangement. To be included in this arrangement, a doctor or health care professional must (1) be a "covered entity" under the Federal Privacy Regulation 45 CFR Part 160, (2) have medical staff privileges or been authorized to participate in patient care by the Medical Staff and CRMC Board of Trustees, and (3) have agreed to participate in the arrangement.


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 at CRMC. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care created or retained by CRMC, whether made by CRMC personnel or your personal doctor.

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.

We are required by law to:

  • Maintain the privacy of protected health information;
  • Provide individuals with notice of our legal duties and privacy practices with respect to protected health information; and
  • Follow the terms of the notice that is currently in effect.


The following categories describe different ways that we use and disclose medical information. 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 categories.

  • For Treatment We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical and/or nursing students, or other health care center personnel who are involved in taking care of you at CRMC. 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. Different departments of CRMC 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 CRMC who may be involved in your medical care after you leave, such as giving instructions to family members who will be driving you home or who will be helping to care for you at home. We may also share your medical information with:

    • Another health care facility who needs your medical information to provide ongoing care or who needs information to evaluate a possible transfer to their facility;
    • The physician who ordered a test and needs the results of the test to diagnose your condition; or
    • A physician who is expected to see you in his/her office or clinic after discharge or release from CRMC.
  • For Payment We may use and disclose medical information about you so that the treatment and services you receive at CRMC 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 health care center 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 your plan will cover the treatment. We may also release certain information to someone who is responsible to pay for your care.
  • For Health Care Operations We may use and disclose medical information about you for CRMC operations. These uses and disclosures are necessary to run CRMC and make sure that all of our patients receive quality care. 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. We may also combine medical information about many CRMC patients to decide what additional services CRMC should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical and/or nursing students, and other CRMC staff for review and learning purposes. We may also combine the medical information we have with medical information from other health care centers 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 medical information so others may use it to study health care and health care delivery without learning the identity of specific patients.
  • Appointment Reminders We may use and disclose medical information to contact you by phone or mail to remind you that you have an appointment at the health care center or a physician's office or clinic. (See section on Right to Request Confidential Communications.)
  • 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 information about you in an effort to raise money for a foundation which helps CRMC provide better services to our community and surrounding counties, including a Cancer Care Fund where we can accept donations to benefit cancer patients.
  • Health Care Center Directory We may include certain limited information about you in the CRMC directory while you are a patient in or receive health care services at CRMC. This information may include your name, location in CRMC, and your general condition (e.g., fair, stable, etc.) The directory information may be released to people who ask for you by name. This is so your family and friends can visit you in CRMC and generally know how you are doing. If you do NOT want to be in the hospital directory, notify the Registrar at the time you check-in to the facility.
  • Clergy/Chaplain Services If you provide your religious affiliation to the Registrar, then your name, location and religious affiliation may be given to a member of the clergy, such as a preacher, minister, priest or rabbi. This provides the opportunity for clergy to visit you in the hospital. If you do NOT wish to be contacted by any clergy member, notify your Registrar.
  • Individuals Involved in Your Care We may release medical information about you to a friend or family member who you allow to be present during your care or who may be involved in your medical care. We may share medical information about unemancipated minors with a parent, legal guardian or other person acting in loco parentis if not otherwise limited by law.
  • Customer Service 
    As part of our customer service program, we may use medical information about you to contact you by mail or phone after discharge to discuss your opinion of the services provided during your encounter with our facility.
  • Follow Up Contact 
    We may use medical information about you to contact you by mail or phone following treatment if it is determined you may require additional follow-up. We may also contact you or your personal doctor to follow up on how you are doing following treatment at CRMC. For example, follow-up information is very important in the area of cancer in order to find the best treatments and improve the life expectancy of people diagnosed with cancer.
  • 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. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but 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 CRMC. We will almost always 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 at CRMC.
  • As Required By Law We will disclose medical information about you when required to do so by federal, state or local law. This may include provision of patient information for State and National registries and databases, that use the data to identify health needs and improve health services.
  • 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.


  • Organ and Tissue Donation 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 worker's compensation or similar programs. These programs provide benefits for work-related injuries or illness. Medical information relating to a Worker's Compensation claim may be released back to the employer and/or insurance carrier who pays for these programs.
  • 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; or
    • To notify the 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 Oversight Activities 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.
  • Emergency/Disaster Situations In the case of a disaster (such as mass casualties), 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.
  • 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, obtain an order protecting the information requested or authorization has been received by you to release the requested information.
  • 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 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 at the health care center; 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 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 health care center to funeral directors as necessary to carry out their duties.
  • National Security and Intelligence Agencies We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security agencies authorized by law.
  • Inmates If you are an inmate of a 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.


You have the following rights regarding medical information we maintain about you. For any of the following rights, forms to help you with the process are available at registration areas, in the Medical Records Department, on our web site, or you can request a form from the Privacy Officer. The address and phone number of the Privacy Officer are listed on the last page of this document.

  • Right to Inspect and Obtain a Copy You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care, unless otherwise limited by law. Usually, this includes medical and billing records, but does not include psychotherapy notes.

    To inspect and obtain a copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer.

    If you request a copy of the information, 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, as permitted by law. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by CRMC 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 If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for CRMC.

    To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide a reason that supports your request.

    We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, 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 the health care center;
    • Is not part of the information which you would be permitted to inspect and copy; or
    • Is accurate and complete.
  • Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you, other than disclosures made for treatment, payment, operations of other reasons where an accounting of disclosures is not required.

    To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer.

    Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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.

  • 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 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.

    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 treatment.

    To request restrictions, you must make your request in writing to the Privacy Officer. 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 health care 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 the Privacy Officer. We will not require a reason for the request. Your request must specify how or where you wish to be contacted, and how payment will be handled, when appropriate. We will accommodate all reasonable requests. CRMC reserves the right to contact you at any known location or in any way legally permitted if payment is overdue, and you do not respond to initial notification.

  • 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 upon request.

    You may obtain a copy of this notice at our website,

  • Personal Representative Your "personal representative" may exercise the rights listed above on your behalf, if under applicable law, that person has legal authority to act on your behalf in making decisions related to health care. If you live in Tennessee and do not have a "personal representative," you may wish to create a legal document called a Durable Power of Attorney for Health Care. This may be extremely beneficial in the unfortunate situation where you are unable to make a decision for yourself and wish for someone to be able to act on your behalf. You may request more information about this from our Registrar or the Social Services Department.


  • 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 CRMC and on our web site. The notice will contain the effective date. If we make a substantial change to the notice, a revised notice will be available to you at the next time you register at CRMC for treatment or health care services as an inpatient or outpatient.


If you believe your privacy rights have been compromised, you may file a complaint with the CRMC Privacy Officer or with the Secretary of the Department of Health and Human Services.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.


Other uses and disclosures of medical information not covered by the categories or specified purposes listed in this notice will be made only with your written authorization.

If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time.

To revoke an authorization. As soon as we receive and process your request to revoke your original authorization, we will then cease to use or disclose medical information about you as was originally permitted. You understand that we are unable to take back any disclosures we have already made prior to revoking your permission.


Privacy Officer 
Cookeville Regional Medical Center 
1 Medical Center Boulevard 
Cookeville, TN 38501 
For more information about this notice, call the Privacy Officer at (931) 783-2710.

Effective Date: April 14, 2003
Revised: October 15, 2009