Who will get this notice?

HealthSource of Ohio provides health care to our patients in partnership with physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:

• All health care professionals who treat you at all of our locations.
• All departments and units of our organization, including our dental offices, WIC, and prenatal services.
• All employed staff or volunteers of our organization including physicians, dentists, nurse practitioners, physician assistants, and social workers.
• Any business associate or partner with whom we share health information.

Our pledge to you

We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor, dentist, social worker, or mid-level provider. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office. Specific policies may apply to particular clinical procedures or diagnoses. We are required by law to:

• keep medical information about you private.
• give you this notice of our legal duties and privacy practices with respect to medical information about you.
• follow the terms of the privacy notice that is currently in effect.

Changes to this notice

We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the new notice in waiting areas, exam rooms, and through other means as they may exist at the time. You can receive a copy of the current notice at any time. The effective date is listed just below the title. You will be offered a copy of the current notice each time you register at our facility for treatment. You will also be asked to acknowledge in writing your receipt of this notice.

How we may use and disclose medical information about you

• We may use and disclose medical information about you for treatment (such as sending information about you to a specialist as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our health care operation (such as comparing patient data to improve treatment methods.)
• We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements, organ donation, workers’ compensation purposes, and emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders, such as a court order or subpoena.
• We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you, or to support fundraising efforts. If you do not want to receive automated reminder notices by telephone, you must indicate this by a written letter.
• In an emergency or in urgent situations, we may disclose medical information about you to a friend or family member who is involved in your medical care, or to disaster relief authorities so that your family can be notified of your location and condition.

Other uses of medical information

• In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you chose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.

Your rights regarding medical information about you

• In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
• If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the records by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend a record.
• You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
• If this notice was sent to you electronically, you have the right to a paper copy of this notice.
• You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.
• You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.

  All written requests or appeals should be submitted to our Privacy Office listed at the bottom of this notice.

Complaints

• If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office at HealthSource of Ohio Network, 400 TechneCenter Drive, Suite 402, Milford, OH 45150. You may also contact the Practice Manager at the HealthSource of Ohio Network Office at which you were seen. View list of offices.
• Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address.
• Under no circumstance will you be penalized or retaliated against for filing a complaint.