PLEASE REVIEW IT CAREFULLY
We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information set forth more fully in 45 CFR Part 164.
1. Uses And Disclosures We May Make Without Written Authorization
We may use or disclose your health information for certain purposes without your written authorization, including the following:
Treatment: We may use or disclose your information for purposes of treating you. We may disclose your information to another health care provider so they may treat you; appointment reminders; or to provide information about treatment alternatives or services we offer.
Payment: We may use or disclose your information to obtain payment for services provided to you.
Healthcare Operations: We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, training of our employees.
Other Uses or Disclosures: We may also use or disclose your information for certain other, applicable laws/regulations, including:
- To avoid a serious threat to your health or safety or the health or safety of others.
- As required by state or federal law such as reporting abuse, neglect or certain other events.
- Worker compensation laws or certain public health activities such as reporting certain diseases.
- For certain public health oversight activities such as audits, investigations, or licensure actions.
- In response to a court order, warrant or subpoena in judicial or administrative proceedings.
- For certain specialized government functions such as the military or correctional institutions.
- For research purposes if certain conditions are satisfied.
- In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes.
- To coroners, funeral directors, or organ procurement organizations.
2. Disclosures We May Make Unless You Object
We may disclose your information as described below.
- To a member of your family, relative, friend, or other person who is involved in your healthcare (added to your communication consent) or payment for your healthcare. We will limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.
- To maintain our facility directory. If a person asks for you by name, we will only disclose your name, general condition, and location in our facility. We may also disclosure your religious affiliation to clergy.
3. Uses and Disclosures with Your Written Authorization
Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes; for most marketing purposes; or if we seek to sell your information. You may revoke your authorization by submitting a written notice to the Privacy Contact identified below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
4. Your Rights Concerning Your Protected Health Information
You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below.
- You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations. We are NOT required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information not be disclosed to a health insurer.
- We normally contact you by telephone or mail at your home address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests.
- You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy. We may charge you a reasonable cost-based fee for providing the records. You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete.
- You may receive an accounting of certain disclosures we have made of your protected health information.
- You may obtain a paper copy of this Notice. You have this right even if you have agreed to receive the Notice electronically.
5. Changes To This Notice
We reserve the right to change the terms of this Notice at any time, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the Notice from our receptionist or Privacy Officer.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint in writing with us by notifying our Privacy Officer. We will not retaliate against you for the complaint.
7. Contact Information
If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above, please contact:
Privacy Officer: Betsy Hackett
Address: 921B Jasonway Ave Columbus, OH 43214
E-mail: [email protected]
8. Effective Date
This Notice is effective September 16, 2013.
*Individual results are not guaranteed and may vary from person to person. Images may contain models.