HIPAA
PRIVACY ACT NOTICE
MANSFIELD/ONTARIO/RICHLAND COUNTY HEALTH DEPARTMENT
NOTICE OF PRIVACY PRACTICES
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.
OUR PLEDGE REGARDING PROTECTED HEALTH
INFORMATION:
We understand that all health information about you is personal
and confidential. We are committed to protecting all medical
information about you. We create a record of care and services
you receive, and use 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 generated by this agency.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health and related care services.
These guidelines are not intended to take the place of any federal or state laws with a greater protection of "protected health information".
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the
physical property of the Mansfield/Ontario/Richland County Health
Department, the information belongs to you. You have the right
to:
_ Request a restriction on certain uses and disclosures of your information;
_ Obtain a paper copy of the notice of information practices upon request;
_ Inspect and obtain a copy of your health record;
_ Amend your health record;
_ Obtain an accounting of disclosures of your health information;
_ Request communications of your health information by alternate means;
_ Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Following is a statement of your rights with respect to your protected
health information and a brief description of how you may exercise
those rights.
You have the right to inspect and obtain
a copy of your protected health information.
This means you may inspect and obtain
a copy of protected health information about you that is contained
in a designated record for as long as we maintain the protected
health information. A record contains medical and/or billing
information and any other records the physician uses for making
decisions about you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstance, you may have a right to have the decision reviewed. Please contact our Privacy Officer if you have any questions.
You have the right to request a restriction
of your protected health information.
You may request that any part of
your protected health information not be disclosed to family members
or friends who may be involved in your care or for notification
purposes as described in this Notice. Your request must state
the specific restriction requested and to whom you want the restriction
to apply.
We are not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If the physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with the physician. You may request a restriction by completing a "Request for Restriction" form.
You have the right to request to receive
confidential communications from us by alternative means or at
an alternative location.
We will accommodate reasonable requests.
We may also condition this accommodation by asking you for information
as to how payment will be handled or specification of an alternative
address or other method of contact. We will not request an explanation
from you as to the basis for the request. This request must be
made in writing.
You may have the right to have your protected
health information amended.
This means you may request an amendment
of protected health information about you in your medical record
for as long as we maintain this information. In certain cases,
we may deny your request for an amendment. If we deny your request
for amendment, you have the right to file a statement of disagreement
with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal. Please contact
our Privacy Officer if you have any questions about amending your
medical record.
You have the right to receive an accounting
of certain disclosures we have made, if any, of your protected
health information,
This right applies to disclosures
for purposes other than treatment, payment or healthcare operations
as described in this Notice. It excludes disclosures we may have
made to you, to family members, or friends involved in your care,
or for notification purposes. You have the right to receive specific
information regarding these disclosures that occurred after April
14, 2003. You may request a shorter time frame. The right to
receive this information is subject to certain exceptions, restrictions
and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
OUR RESPONSIBILITIES
The Mansfield/Ontario/Richland County
Health Department is required to:
_ Maintain the privacy of your protected health information
_ Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
_ Abide by the terms of this notice
_ Notify you if we are unable to agree to a requested restriction
_ Accommodate reasonable requests you may have to communicate health information by alternate means or at alternate locations
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.
We will not disclose your health information without your authorization, except as described in this notice.
Examples of Disclosures for Treatment,
Payment and Health Operations
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 students, or other agency personnel involved in taking
care of you. 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
an appropriate plan. Different departments of the agency also
may share medical information about you in order to coordinate
the different things you need, such as prescriptions, lab work,
x-rays. We also may disclose medical information about you to
another provider outside the department who may be involved in
your medical care after you leave the department, such as family
members, or others we use to provide services (i.e. home health
aides, physical therapist, specialist, or other community resources)
that are part of your care.
Payment Information: A bill may be sent to you or a third
party-payer, such as Medicare, Medicaid, or private insurance.
The information on or accompanying the bill may include information
that identifies you, as well as your diagnosis, procedures, and
supplies used. 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.
Health Care Operations: Members of the medical staff, the risk or quality improvement team may use information in your health record to assess the care and outcome in your case and others like it. The information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service provided. These uses and disclosures are necessary to run the agency and make sure that all of our patients receive quality care.
Business Associates: We will share your protected health information with third party "business associates" that facilitate activities (i.e., billing, and lab tests) for the agency. Whenever an arrangement between the agency and a business associate involves the use or disclosure of your protected health information a written contract that contains terms that will protect the privacy of your protected health information will be in place.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. Please refer to your right to restrict communication.
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. This may be in the form of newsletters or brochures mailed to your residence.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition 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.
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 receive one medication to those who receive 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 the protected health information. Before we use or disclose health information for research, the project will have been approved through this research approval process.
However, we may disclose protected health 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 health information they review does not leave the agency. 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 the agency.
As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.
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 health and safety of the public or another person. Any disclosures, however, would only be to someone able to help prevent the threat.
SPECIAL SITUATIONS:
Organ and Tissue Donation: If you
are an organ donor, 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 or Veterans: If you are a member of the armed forces, we may release protected health 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.
We may use and disclose to components of the Department of Veterans Affairs protected health information about you to determine whether you are eligible for certain benefits.
Workers Compensation: We may release medical information about you for workers compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include (but are not exclusive to) 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;
· 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, audit 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.
Law Enforcement: We may release medical information if asked to do so by law enforcement officials:
_ 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 criminal conduct at the clinic agency; 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 to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.
Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
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.
COMPLAINTS
If you believe your privacy rights
have been violated, you may file a complaint with our Privacy
Officer or with the Secretary of the Department of Health and
Human Services. To file a complaint with the Privacy Officer,
contact Cathy Smith, Human Resources Manager, (419) 774-4500.
All complaints must be in writing.
You will not be penalized for filing a complaint.
Effective date: April 14, 2003.
WRITTEN ACKNOWLEDGMENT
I
acknowledge that I have reviewed the Notice of Privacy Practices issued by the
Mansfield/Ontario/Richland County Health Department which provides a description
of information uses and disclosures. I understand that I have the right to request
restrictions as to how my health information may be used or disclosed and that
the organization is not required to agree to the restrictions I requested.
Patient Name:
Last First Middle (Previous Last Name)
Patient Date of Birth:
Signature of Patient or Legal Representative Date
Print Name
Relationship to Patient