This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully.
Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information. Your information may be stored electronically and if so is subject to electronic disclosure.
How We Use & Disclose Your Patient Health Information
Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.
Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment or disclose your information to payers to determine whether you are enrolled or eligible for benefits. We will submit bills and maintain records of payments from your health plan.
Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, arranging for legal services and to assess the care and outcomes of your case and others like it.
Special Uses and Disclosures
Following a procedure, we will disclose your discharge instructions and information related to your care to the individual who is driving you home from the center or who is otherwise identified as assisting in your post-procedure care. We may also disclose relevant health information to a family member, friend or others involved in your care or payment for your care and disclose information to those assisting in disaster relief efforts.
Other Uses and Disclosures
We may be required or permitted to use or disclose the information even without your permission as described below:
Required by Law: We may be required by law to disclose your information, such as to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.
Research: We may use or disclose information for approved medical research.
Public Health Activities: We may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.
Health Oversight: We may disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.
Judicial and Administrative proceedings: We may disclose information in response to an appropriate subpoena, discovery request or court order.
Law Enforcement purposes: We may disclose information needed or requested by law enforcement officials or to report a crime on our premises.
Deaths: We may disclose information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.
Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.
Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness.
Business Associates: We may disclose your health information to business associates (individuals or entities that perform functions on our behalf) provided they agree to safeguard the information.
Messages: We may contact you to provide appointment reminders or for billing or collections and may leave messages on your answering machine, voicemail or through other methods.
Fundraising: We may contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt out” of receiving fundraising materials/communications and may do so by sending your name and address to the Privacy Officer together with a statement that you do not wish to receive fundraising materials or communications from us.
In any other situation, we will ask for your written authorization before using or disclosing identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your health information for marketing purposes or sell your health information, unless you have signed an authorization.
- You have the following rights with regard to your health information. Please contact the Privacy Officer to obtain the appropriate form for exercising these rights.
- You may request restrictions on certain uses and disclosures. We are not required to agree to a requested restriction, except for requests to limit disclosures to your health plan for purposes of payment or health care operations when you have paid in full, out-of-pocket for the item or service covered by the request and when the uses or disclosures are not required by law.
- You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.
- In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for copies.
- You have the right to request that we amend your information.
- You may request a list of disclosures of information about you for reasons other than treatment, payment, or health care operations and except for other exceptions.
- You have the right to obtain a paper copy of the current version of this Notice upon request, even if you have previously agreed to receive it electronically.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, to abide by the terms of the Notice currently in effect and to notify you if we are unable to agree to a requested restriction. We are required to notify affected individuals in the event of a breach involving unsecured protected health information.
Changes in Privacy Practices
We may change this Notice at any time and make the new terms effective for all health information we hold. If we change our Notice, we will post the current Notice in the waiting area and on our website. You may also request a current copy of by phone or by mail. For more information about our privacy practices, contact the Privacy Officer.
If you are concerned that we have violated your privacy rights, you may contact the Privacy Officer. You also may send a written complaint to the U.S. Department of Health and Human Services. The Privacy Officer will provide you with the appropriate address upon request. You will not be penalized in any way for filing a complaint. If you have any questions, requests or complaints, please contact the Privacy Officer at (937) 535-2200.
Acknowledgement of Receipt of Notice: You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.
Effective Date: 9-1-2006