NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW WE CAN USE AND DISCLOSED
HEALTH INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.
THE PRIVACY OF YOUR HEALTH RECORD IS IMPORTANT
TO US.
OUR LEGAL DUTY
Federal and state law requires us to maintain the
privacy of your health information. That law also requires us to
give you this notice about our privacy practices, our legal duties,
and your rights concerning your health information. We must follow
the privacy practices we describe in this notice while it is in
effect. This Notice takes effect April 14, 2003, and will remain
in effect until we replace it.
We reserve the right to change our privacy practices
and the terms of our notice effective for all health information
that we maintain, including health information we created or received
before we made the changes. Before we make a significant change
in our privacy practices, we will change the Notice and make new
Notices available upon request.
You may request a copy of our Notice or more information
about our privacy practices at any time by contacting our office
directly.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you
for treatment, payment , and healthcare operations. For Example:
Treatment: We may use your health information
for treatment or disclose it to a dentist, physician, or other health
care provider involved in your treatment.
Payment: We may use and disclose your health
information to obtain payment for services we provide to you;we
may aldo disclose your health information to another health care
provider or entity that is subject to the federal Privacy Rules
for its payment activities.
Healthcare Operations: We may use and disclose
your health information for our health care operations (quality
assessment and improvement activities, reviewing the competence
or qualifications of health care professionals, evaluating practitioner
and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities). We may also
disclose your health information to another health care provider
or organization that is subject to the federal Privacy Rules and
that has a relationship with you to support some of their health
care operations. We may disclose your information to help these
organizations conduct quality assessment and improvement activities,
review the competence or qualifications of health care professionals,or
detect or prevent health care fraud and abuse.
On Your Authorization: You may give us written
authorization to use your health information or to disclose it to
anyone for any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not effect
any use or disclosures permitted by your authorization while it
was in effect. Unless you give us a written authorization, we cannot
use or disclose your health information for any reason except those
described in this notice.
To Your Family and Friends: We may disclose
your health information to a family member,friend,or other person
to the extent necessary to help with your health care or with payment
for your health care. Before we disclose your health information
to these people, we will provide you with an opportunity to object
to our use or disclosure. If you are not present, or in the event
of your incapacity or an emergency, we will disclose your medical
information based on our professional judgement of whether the disclosure
of this information would be in your best interest. We may use our
professional judgement and our experience with common practice to
make reasonable inferences of your best interest in allowing a person
to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of health information. We may use or disclose information
about you to notify or assist in notifying a person involved in
your care of your location and general condition.
Appointment Reminders: We may use or disclose
your health information to provide you with appointment reminders
(such as voicemail messages,e-mail, postcards, or letters).
Disaster Relief: We may use or disclose
your health information to a public or private entity authorized
by law or by its charter to assist in disaster relief efforts.
Public Benefit: We may use or disclose your
medical information as authorized by law for the following purposes
deemed to be in the public interest or benefit:
- as required by law;
- for public health activities, including disease and vital statistic
reporting, child abuse reporting, FDA oversight, and employers
regarding work-related illnesses or injury;
- to report adult abuse, neglect, or domestic violence;
- to health oversight agencies;
- in response to court and administrative orders and other lawful
processes;
- to law enforcement officials pursuant to subpoenas and other
lawful processes concerning crime victims, suspicious deaths,
crimes on our penalties, reporting crimes in emergencies, and
for purposes of identifying or locating a suspect or other person;
- to coroners, medical examiners, and funeral directors;
- to organ procurement organizations;
- to avert a serious threat to health or safety;
- in connection with certain research activities;
- to the military and to federal officials for lawful intelligence,
counterintelligence, and national security activities;
- to correctional institutions regarding inmates;
- as authorized by state worker's compensation laws.
PATIENT RIGHTS
Access: You have
the right to look at or get copies of your health information, with
limited exceptions. You may request that we provide copies in a
format other than photocopies. We will use the format you request
unless we cannot practicably do so. You must make a request in writing
to obtain access to your health information. You may request access
by sending us a letter to the address at the end of this Notice.
If you request copies, we will charge you a reasonable cost based
fee that may include labor, copying costs, and postage. If you request
an alternative format, we will charge a cost-based fee for providing
your health information in that format. If you prefer, we may (but
are not required to) prepare a summary or an explanation of your
health information for a fee. Contact us using the information address
below for more information about fees.
Restriction: You have the right to request
that we place additional restrictions on our use or disclosure of
your health information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except
in an emergency). Any agreement we may make to a request for additional
restrictions must be in writing signed by a person authorized to
make such an agreement on our behalf. Your request is not binding
unless our agreement is in writing.
Alternative Communication: You have the
right to request that we communicate about your health information
by alternative means or to alternative locations. You must make
your request in writing. Your must specify in your request the alternative
means or location, and provide satisfactory explanation of how you
will handle payment under the alternative means or location that
you request.
Amendment: You have the right to request
that we amend your health information. Your request must be in writing,
and it must explain why we should amend the information. We may
deny your request under certain circumstances.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy
practices or have questions or concerns, please contact us using
the information listed at the end of the Notice. If you believe
that we may have violated your privacy rights, we made a decision
about access to your health information incorrectly, our response
to a request that you made to amend or restrict the use or disclosure
of your health information was incorrect, or we should communicate
with you by alternative means or at alternative locations, you may
contact us using the information listed below. You also may submit
a written complaint to the U.S. Department of Health and Human Services.
Upon request, we will provide you with its address to file your
complaint. We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
CONTACT:
Kevin D. Huff
ATTN: HIPAA Compliance Officer
217 West Fourth Street
Dover, OH 44622
Telephone: (330) 364-2011
Facsimile: (330) 602-3001
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