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MID OHIO PULMONARY AND SLEEP
ASSOCIATES, INC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
State and Federal laws require us to maintain the
privacy of your health information and to inform you
about our privacy practices by providing you with this
Notice. We must follow the privacy practices as
described below. This Notice will take effect on
February 1st, 2006 and will remain in effect until it is
amended or replaced by us.
It is our right to change our privacy practices provided
law permits the changes. Before we make a significant
change, this Notice will be amended to reflect the
changes and we will make the new Notice available upon
request. We reserve the right to make any changes in our
privacy practices and the new terms of our Notice
effective for all health information maintained, created
and/or received by us before the date changes were made.
You may request a copy of our Privacy Notice at any time
by contacting our Privacy Officer (Dianne Stansifer).
Information on contacting us can be found at the end of
this Notice.
TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION
We will keep your health information confidential, using
it only for the following purposes:
Treatment: We may use your health information to
provide you with our professional services. We have
established “minimum necessary or need to know”
standards that limit various staff members’ access to
your health information according to their primary job
functions. Everyone on our staff is required to sign a
confidentiality statement.
Disclosure: We may disclose and/or share your
healthcare information with other health care
professionals who provide treatment and/or service to
you. These professionals will have a privacy and
confidentiality policy like this one. Health information
about you may also be disclosed to your family, friends
and/or other persons you choose to involve in your care,
only if you agree that we may do so.
Payment: We may use and disclose your health
information to seek payment for services we provide to
you. This disclosure involves our business office staff
and may include insurance organizations or other
businesses that may become involved in the process of
mailing statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health
information to notify, or assist in the notification of
a family member or anyone responsible for your care, in
case of any emergency involving your care, your
location, your general condition or death. If at all
possible we will provide you with an opportunity to
object to this use or disclosure. Under emergency
conditions or if you are incapacitated we will use our
professional judgment to disclose only that information
directly relevant to your care. We will also use our
professional judgment to make reasonable inferences of
your best interest by allowing someone to pick up filled
prescriptions, x-rays or other similar forms of health
information and/or supplies unless you have advised us
otherwise.
Healthcare Operations: We will use and disclose
your health information to keep our practice operable.
Examples of personnel who may have access to this
information include, but are not limited to, our medical
records staff, outside health or management reviewers
and individuals performing similar activities.
Required by Law: We may use or disclose your
health information when we are required to do so by law.
(Court or administrative orders, subpoena, discovery
request or other lawful process.) We will use and
disclose your information when requested by national
security, intelligence and other State and Federal
officials and/or if you are an inmate or otherwise under
the custody of law enforcement.
Abuse or Neglect: We may disclose your health
information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse,
neglect, or domestic violence or the possible victim of
other crimes. This information will be disclosed only to
the extent necessary to prevent a serious threat to your
health or safety or that of others.
Public Health Responsibilities: We will disclose
your health care information to report problems with
products, reactions to medications, product recalls,
disease/infection exposure and to prevent and control
disease, injury and/or disability.
Marketing Health-Related Services: We will not
use your health information for marketing purposes
unless we have your written authorization to do so.
National Security: The health information of
Armed Forces personnel may be disclosed to military
authorities under certain circumstances. If the
information is required for lawful intelligence,
counterintelligence or other national security
activities, we may disclose it to authorized federal
officials.
Appointment Reminders: We may use or disclose
your health information to provide you with appointment
reminders, including, but not limited to, voicemail
messages, postcards or letters.
YOUR PRIVACY RIGHTS AS OUR PATIENT
Access: Upon written request, you have the right
to inspect and get copies of your health information
(and that of an individual for whom you are a legal
guardian.) There will be some limited exceptions. If you
wish to examine your health information, you will need
to complete and submit an appropriate request form.
Contact our Privacy Officer for a copy of the Request
Form. You may also request access by sending us a letter
to the address at the end of this Notice. Once approved,
an appointment can be made to review your records.
Copies, if requested, will be $ 1 for each page for
first 10 pages and then 10 cents per page. If you want
the copies mailed to you, postage will also be charged.
If you prefer a summary or an explanation of your health
information, we will provide it for a fee. Please
contact our Privacy Officer for a fee and/or for an
explanation of our fee structure.
Amendment: You have the right to amend your
healthcare information, if you feel it is inaccurate or
incomplete. Your request must be in writing and must
include an explanation of why the information should be
amended. Under certain circumstances, your request may
be denied.
Non-routine Disclosures: You have the right to
receive a list of non-routine disclosures we have made
of your health care information. (When we make a routine
disclosure of your information to a professional for
treatment and/or payment purposes, we do not keep a
record of routine disclosures: therefore these are not
available.) You have the right to a list of instances in
which we, or our business associates, disclosed
information for reasons other than treatment, payment or
healthcare operations. You can request non-routine
disclosures going back 6 years. Information prior to
that date would not have to be released.
Restrictions: You have the right to request that
we place additional restrictions on our use or
disclosure of your health information. We do not have to
agree to these additional restrictions, but if we do, we
will abide by our agreement. (Except in emergencies.)
Please contact our Privacy Officer if you want to
further restrict access to your health care information.
This request must be submitted in writing.
QUESTIONS AND COMPLAINTS
You have the right to file a complaint with us if you
feel we have not complied with our Privacy Policies.
Your complaint should be directed to our Privacy
Officer. If you feel we may have violated your privacy
rights, or if you disagree with a decision we made
regarding your access to your health information, you
can complain to us in writing. Request a Complaint Form
from our Privacy Officer. We support your right to the
privacy of your information and 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.
HOW TO CONTACT US
| Practice Name: |
|
Mid Ohio Pulmonary And Sleep
Associates, Inc. |
| Privacy Officer: |
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Dianne Stansifer |
| Telephone: |
|
(614) 586 0668 Fax: (614) 586
0669 |
| Address: |
|
2760 Airport Drive, Suite 120
Columbus, Ohio 43219. |
HIPAA Notice of Privacy Practices
This form does not constitute legal advice and
covers only federal, not state, law.
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