PRIVACY PRACTICE STATEMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

I. This is a formal notification, as required by the government concerning the privacy policy of this practice. This practice has an obligation to maintain all medical information in the strictest of confidence. Our practice cannot release information without your written consent, including medical records, conversations, reminder calls, test results and other confidential issues. Patient information about health care is identified as "PHI" or protected health information. This new policy requires that you, the patient, identify at the time of registration with us specific information about release of information. You can change this information at any time with either written
notification or verbal notification, followed up in writing. Changes can only impact the care or information from that point in time forward.
II. Your protected health information (PHI) is a part of your medical care, and can be used or disclosed as follows:
• For your treatment in this practice and other locations under the our immediate care for care needs. This may include any prevention or medical condition evaluation and exam, procedures done related to your care needs, medication management, hospice, VNA support, Nursing Home care, referral for services, diagnostic tests or treatment related to your medical care needs. This includes release of information to family and significant other, husband or wife.
• For obtaining payment for treatment with your identified health care program. This would include any documentation related to this care, including history forms, progress notes, and procedure notes. This would include eligibility verification, prior authorization and claim submission.
• For operations of this practice, such as enrolling with insurance programs, hospital privileges, accounting and compliance with federal and state laws and regulations.
• Appointment reminders and health related benefit services only with your consent identified on the registration form.
• Disclosure to your family and friends concerning any related health care information with your on the registration form which can be modified at any time orally, followed by written consent.
• Consent is not required for emergency care and treatment. An emergency is identified as a medical condition that in the judgment of the physician requires information for care on your behalf.
Certain disclosures can be made without your consent, and they are as follows:
• Disclosure required by the government or law enforcement agencies. An example would be victims of abuse
• Information used for public health purposes, medical examiners or related to a person's death or for the health department for disease tracking.
• Information used for health care oversight, such as a site review by an insurance program.
• For worker's compensation cases or employment related assessments
III. Your rights for your health information include: The right to request limits on the uses and disclosure at registration or any time during your care. The right to choose how we send this information to you, including an alternate address.
The right to see and obtain copies of your PHI, but there may be copy and postage fees. The right to get a listing of who we have made disclosures to about your PHI. The right to correct your file through an amendment process if appropriate.
IV. This practice reserves the right to modify or change this Privacy Statement and process at any time. Revision to the Notice will be available upon request by contacting the office. The changes will be effective retroactively to the initial date of the Privacy Notice. An updated Privacy Notice will be posted in the office within 60 days of the revision.
VI. If you have a concern or complaint about how your protected health information is being used, from this time forward you should first contact our Practice Administrator at our Business office to resolve your concerns or you may contact the Office of Civil Rights or the Ohio Medicare Carrier, GBA Palmetto.

Office of Civil Rights - Regional Manager Palmetto GBA
Department of Health & Human Services Part B Operations – HIPAA Compliance Concerns
233 N. Michigan Avenue, Suite 240 PO Box 18957
Chicago, Illinois 60601

Office of Civil Rights - Regional Manager
Department of Health & Human Services
233 N. Michigan Avenue, Suite 240
Chicago, Illinois 60601