Asquam Community Healthcare Collaborative

Organized Health Care Arrangement (OHCA)Notice of Privacy Practices


The Asquam Community Healthcare Collaborative is comprised of LRGHealthcare, which includes Lakes Region General Hospital in Laconia, N.H., and Franklin (N.H.) Regional Hospital, Speare Memorial Hospital in Plymouth, N.H. as well as each of their respective ambulatory facilities and physician practices.  The collaborative was formed in order to improve coordination, quality and efficiency of medical care in the communities it serves by sharing a clinically integrated electronic health record system. As a result of this integration, these organizations function as an Organized Health Care Arrangement (OHCA) as defined by the Health Insurance Portability and Accountability Act (HIPAA). For purposes of this notice, the members of the Asquam OHCA are collectively referred to in this document as “Asquam.”

The organizations within the Asquam Community Healthcare Collaborative collect and receive information about your past, present or future health condition to provide health care to you, to receive payment for this health care, or to operate the hospitals, practices and/or clinics. All Asquam providers, independent or private practice physicians and allied health care professionals who have been accepted as members of the Asquam Medical Staff and who work as members of the Asquam team in providing your health care and improving our health care operations have access to your medical record, whether in paper or electronic format.

The organizations within the Asquam Community Healthcare Collaborative pledge to give you the highest quality health care and to have a relationship with you that is built on trust. This trust includes our commitment to respect the privacy and confidentiality of your health information.

Who must follow this Notice:

  • All members of our workforce including doctors, nurses, other health care providers, other employees, staff and volunteers;
  • All members of our Medical Staff and other persons who participate in Asquam’s organized health care arrangement.

This Notice is being given to you because federal law gives you the right to be told ahead of time about:

How the organizations within the Asquam Community Healthcare Collaborative will handle your health information;

Their legal duties related to your health information; and

Your rights with regard to your health information.

Patient-specific information is confidential and shall be made available only in conformity with all applicable state and federal laws and regulations regarding the confidentiality of patient records, including but not limited to, 42 CFR Part 2, and 45 CFR Parts 160 and 164 (HIPAA Privacy and Security Rules) where applicable.

Each time you visit your doctor, a hospital, or other care providers, a record of your visit is made. This record usually contains your symptoms, examination or test results, diagnosis, treatment, a plan for any future care or treatment you may need, and often, it also includes payment information. This is called your health or medical record.

Although your medical record is the physical property of the healthcare provider or facility that compiled it, the information it contains belongs to you. For the purpose of this document, Asquam will refer to that information as "Protected Health Information," or "PHI."

Asquam will not condition your treatment or payment on your signing this document.


You have the right to:

  • Obtain a paper copy of this notice, or upon your request, any future revisions of this notice;
  • Request a restriction on certain uses and disclosures of your PHI (though Asquam is not required to agree to any such request);
  • Review and get a paper or electronic copy of your PHI. If you request a copy of the information, you may be charged a fee for the costs of copying, mailing or other supplies used to fulfill your request. If you would like an electronic copy of your health information, it will be provided to you as a copy in electronic form and format as requested as long as it can be readily produced in the form requested. Otherwise, a readable electronic form and format will be provided as agreed;
  • Request that your provider correct or update your PHI if you believe that there is a mistake in your record, or an important piece of information is missing;
  • Obtain a list of disclosures of your PHI made after April 14, 2003, for purposes other than treatment, payment, or healthcare operations;
  • Receive confidential communications of PHI, choose how PHI is sent to you if you prefer an alternate form of communications to traditional mail, and choose if you wish to have your PHI sent to a different address;
  • Withdraw your authorization to use or disclose your PHI except to the extent that action has already been taken;
  • Receive notification if there is a probable compromise of your unsecured PHI within sixty (60) days of the discovery of the breach. The notice will include a description of what happened, including the date, the type of information involved in the breach, steps you should take to protect yourself from potential harm, a brief description of the investigation into the breach, mitigation of harm to you and protection against further breaches and contact procedures to answer your questions;
  • All requests for the release of PHI must be made in writing, and must be signed by the patient or responsible party. Requests may be made through Health Information Management Services at each Asquam hospital, clinic or physician practice where you were seen and treated.


Each Asquam hospital, clinic or physician practice where you were seen and treated  is required to:

  • Maintain the privacy of your PHI;
  • Provide you with a notice as to our legal duties and privacy practices with respect to information collected and maintained about you, and abide by the terms of this notice;
  • In the event that your request is denied to review and get a paper or electronic copy of your PHI, you will be informed in writing and explain whether you can appeal your denial, and if so, how that process works;
  • Notify you in writing if your request is denied to change your PHI, which an Asquam provider may do if it finds that your medical record is accurate and complete; it was not created by us; your requested change is to information to which your provider is not required to provide access; or if your requested change is to information that is not part of our records;
  • Notify you if the requested restriction is denied;
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations;
  • All providers within the Asquam Community Healthcare Collaborative reserve the right to change our privacy practices and to make those changes effective for all protected health information collected prior to the date of the change. Should our information practices change, we will make available to you, at your request, a revised paper copy of our Notice of Privacy Practices. Our current Notice of Privacy Practices will always be posted on our website at


There are many ways in which hospitals and providers use and disclose a patient’s PHI. For some of these uses, your provider is required to get your written consent; for others, they are not. Below please find a list of how Asquam may use and disclose your PHI:

A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations.

Your PHI may be used and disclosed without your prior consent for the following reasons:

  1. For treatment. As your provider, we may use your health information to provide you with healthcare treatment and services. For example, information collected by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will note in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, your physician will know how you are responding to treatment.
  2. For payment. As your provider we may use or disclose your health information so that Asquam may bill and receive payment from you, an insurance company, or another third party for the healthcare services you receive from us. For example, a bill may be sent to you or your insurance company. The information sent with the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
  3. For health care operations. As your provider, we may use or disclose your health information in order to perform the necessary administrative, educational, quality assurance, and business functions of our facilities. For example, members of the medical staff, the risk management director, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to improve the quality and effectiveness of the healthcare and services Asquam provides. While Asquam may also provide your PHI to our accountants, attorneys, consultants, business associates, and others in order to make sure Asquam is complying with the laws and business practices that affect us and to conduct hospital business, Asquam will make every effort to protect the privacy of your PHI.

B. Uses and Disclosures for Patient Directories and to Persons Assisting in Your care

Generally, as your provider, we will get your verbal consent before using or disclosing PHI in the following ways. However, in certain situations, such as an emergency, as your provider, we may use and disclose your PHI for these purposes without your consent.

  1. Patient directories. As your provider, we may include your name, location, general condition, and religious affiliation in a patient directory. Clergy members who ask for you by name may be given this information. Visitors who ask for you by name may be given your location and general condition. Members of the media who ask for you by name may receive confirmation that you are a patient, and be provided with your general condition.
  2. Disclosures to family, friends or others. As your provider, we may provide your PHI, including your condition and status, to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, including following your death. In addition, as your provider, we may disclose health information about you to an entity assisting in a disaster relief effort so that a family member or other person responsible for your care can be notified about your condition, status and location.

C. Other Uses and Disclosures that Do Not Require Your Authorization

Providers within the Asquam Community Healthcare Collaborative may use and disclose your PHI without your consent or authorization for the following reasons:

  1. Appointment Reminders: As your provider, we may use and disclose PHI to contact you as a reminder that you have an appointment for tests or treatment, or a prescription refill;
  2. Treatment Alternatives: As your provider, we may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you;
  3. Health-Related Benefits and Services: As your provider, we may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you;
  4. Research: As your provider, we may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information;
  5. To Avert a Serious Threat to Health or Safety: As your provider, we may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any such disclosure, however, would be to someone able to help prevent the threat;
  6. Organ and Tissue Donation: If you are an organ donor, Asquam may release PHI about you 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;
  7. Military and Veterans: If you are a member of the armed forces, as your provider, we may release PHI about you as required by military command authorities;
  8. Workers' Compensation: As your provider, we may release your PHI for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. The exception to this occurs when the information is particularly sensitive (such as drug and alcohol testing results and AIDS results): in those cases, a written release is required.
  9. Public Health risks: As your provider, we may disclose PHI about you for public health activities. These activities generally include the following:
    1. Preventing or controlling disease, injury or disability;
    2. Reporting births and deaths;
    3. Reporting child abuse or neglect;
    4. Reporting reactions to medications or problems with products;
    5. Notifying people of recalls of products they may be using;
    6. Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  1. Victims of Abuse, Neglect or Domestic Violence: As your provider, we may notify the appropriate agencies if Asquam believe a patient has been the victim of abuse, neglect or domestic violence. We will only make such disclosures if you agree or when required or authorized by law;
  2. Health Oversight Activities: As your provider, we may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure;
  3. As Required by Law: As your provider, we will disclose your PHI when required to do so by federal, state or local law. We may also disclose PHI about you in response to a court or administrative order, in response to a subpoena, discovery request, or other lawful process;
  4. Law Enforcement: As your provider, we may release your PHI for law enforcement purposes as required by law or in response to valid legal process. We are also required to report to law enforcement all information regarding the treatment of injuries believed to be caused by a criminal act. The exception to this is in the case of sexual assault victims over the age of 18, unless that patient is also being treated for a life-threatening injury;
  5. Coroners, Medical Examiners and Funeral Directors: As your provider, we may release PHI to a coroner or medical examiner. We may also release PHI to funeral directors as necessary to carry out their duties;
  6. National Security and Intelligence Activities: As your provider, we may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law;
  7. Protective Services for the President and Others: As your provider, we may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations;
  8. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, as your provider, we may disclose to the institution and its agents health information necessary for your health and the safety of other individuals;
  9. Business Associates: As your provider, we may disclose your health information to contractors, agents and other "business associates" who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, Asquam may share your health information with a billing company that helps us to obtain payment from your insurance company, or Asquam may share your health information with an accounting firm or law firm that provides professional advice to us. If your health information is disclosed to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your health information. If our business associate discloses your health information to a subcontractor or vendor, the business associate will have a written contract to ensure that the subcontractor or vendor also protects the privacy of the information;
  10. Proof of Immunization: As your provider we may disclose proof a child's immunization to a school, about a child who is a student or prospective student of the school, as required by State or other law, if a parent, guardian, other person acting in loco parentis, or an emancipated minor, authorizes us to do so, but Asquam do not need written authorization;
  11. Completely De-identified Or Partially De-identified Information: As your provider we may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information " we may also use and disclose "partially de‑identified” or is "completely de-identified" health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number);
  12. Incidental Disclosures: While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information;
  13. Fundraising: As your provider we may use or disclose your demographic information, including, name, address, other contact information, age, gender, and date of birth, dates of health service information, department of service information, treating physician, outcome information, and health insurance status for fundraising purposes. With each fundraising communication made to you, you will have the opportunity to opt-out of receiving any further fundraising communications. Asquam will also provide you with an opportunity to opt back in to receive such communications if you should choose to do so.

D. All Other Uses and Disclosures. Generally, we will obtain your written authorization before using your health information or sharing it with others outside of our hospital. There are certain situations where we must obtain your written authorization before using your health information or sharing it, including:

  1. Marketing. As your provider we may not disclose any of your health information for marketing purposes if we will receive direct or indirect financial remuneration not reasonably related to our cost of making the communication.
  1. Sale of Protected Health Information. As your provider we will not sell your protected health information to third parties. The sale of protected health information, however, does not include a disclosure for public health purposes, for research purposes where we will only receive remuneration for our costs to prepare and transmit the health information, for treatment and payment purposes, for the sale, transfer, merger or consolidation of all or part of our hospital, for a business associate or its subcontractor to perform health care functions on our behalf, or for other purposes as required and permitted by law.

If you provide us with written authorization, you may revoke that written authorization at any time, except to the extent that we have already relied upon it. To revoke a written authorization, please write to the Privacy Officer where you received treatment. You may also initiate the transfer of your records to another person by completing a written authorization form.

Additionally, there are some kinds of information, such as HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information, are considered so sensitive that state or federal laws provide special protections for them. Therefore, some parts of this general Notice of Privacy Practices may not apply to these types of information. If you have questions or concerns about the ways these types of information may be used or disclosed, please speak with your health care provider.

If a particular situation is not described in sections III. A, B, C and D above, we will ask for your written consent before using or disclosing any of your PHI.


If you think your privacy rights may have been violated, or you disagree with a decision Asquam made about access to your PHI, you may file a complaint with the office listed in the next section of this Notice. Please be assured that you will not be penalized and there will be no retaliation for voicing a concern or filing a complaint. The Asquam Community Healthcare Collaborative is committed to the delivery of quality health care in a confidential and private environment. 

PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES  If you have any questions about this Notice or any complaints about our privacy practices, or you believe your privacy rights have been violated,  please call the Privacy Officer (603)238-6467, the Privacy Hotline (603)238-6467, or contact in writing: HIPAA Privacy Officer at: 16 Hospital Road, Plymouth, NH 03264

You may also file a complaint with the Secretary to the Department of Health and Human Services at:

Department of Health and Human Services
Office for Civil Rights—Region I
JFK Federal Building, Room 1875
Government Center
Boston, MA 02203-0002

Phone: (800) 368-1019 or (617) 565-1340

Fax: (617) 565-3809

TDD: (800) 537-7697 or (617) 565-1343

Web site:
Click on link "How to file a complaint"

Government regulations require that healthcare organizations must state in their privacy notices that no retaliation will be taken against any person for filing a complaint. Consistent with this regulation, as your provider, we will not take any action that would penalize you for exercising your rights as outlined in this privacy notice. Your choice to file a complaint will not affect your current or future care at Asquam or any of our providers.

The Asquam Community Healthcare Collaborative values and welcomes your feedback.




Revised: 4/2017

Path: G:MedicalRecords/Forms

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