- THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Roberta June Guibord D.O., Inc. is dedicated to protecting your medical information. We are required to provide you with this Notice of Privacy Practices and our legal duties with respect to our use and disclosure of your protected health information. This Notice applies to Roberta June Guibord D.O., Inc. at 900 W. So. Boundary St. 3B, Perrysburg Ohio 43551 operating as a physicians office composed of employees and clinical professionals seeing and treating patients at Roberta June Guibord D.O., Inc.
II. USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
A.USES AND DISCLOSURES THAT DO NOR REQUIRE YOUR AUTHORIZATION
1. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS.
We will make uses and disclosures of your personal health information as necessary for your treatment.
We will use and disclose your personal health information for the payment purposes of those health professionals and facilities that have treated you or provided services to you.
We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations, which include clinical improvement, professional peer review, business management, accreditation and licensing, and public relation activities. We may also disclose your personal health information to another health care facility, health care provider, or health plan for such things as quality assurance and case management, but only if that facility, provider, or plan also has or had a treatment relationship with you.
2. FAMILY AND FRIENDS INVOLVED IN YOUR CARE. Disclosures of your personal health information may be made to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care, unless you choose not to approve the disclosure. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individuals without your approval. We also may disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in your care.
3. APOINTMENT AND SERVICES. We may contact you to provide APPOINTMENT REMINDERS, TO SCHEDULE TESTS OR TO PROVIDE TEST RESULTS. You have the right to request, and we will accommodate reasonable requests by you, to receive communications regarding your personal health information from us by alternative means. You may submit such a request in writing to our office, 900 W. So. Boundary St. 3B, Perrysburg Ohio 43551.
4. BUSINESS ASSOCIATES, FUNDRAISING AND HEALTH PRODUCTS AND SERVICES. Some of our services are performed through contracts with outside persons or organizations. In order for us to carry out our health care operations, it may be necessary for us to provide your personal health information to one or more of these outside persons or organizations. We require these business associates to appropriately safeguard the privacy of your information.
We may from time to time use your personal health information to communicate with you about health products and services related to your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.
5. OTHER USES AND DISCLOSURES. We are permitted or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization, including, but not limited to the following:
a. For any purpose required by federal, state, or local law, judicial or administrative proceedings, or law enforcement, such as when reporting gunshot or other wounds or when ordered by the court;
b. For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
c. If we suspect child abuse or neglect; we may also release your personal health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
d. To the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
e. To your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
- If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
g. If required to do so by subpoena or discovery request; in some cases you will have notice of such release;
h. To law enforcement officials as required by law to report wounds and injuries and crimes;
- To coroners, medical examiners and/or funeral directors consistent with law;
- In limited instances if we suspect a serious threat to health or safety of a person or to the public, we may give your information to law enforcement personnel or persons able to prevent or lessen such harm;
k. If you are a member of the military or a veteran as required by armed forces services; we may also release your personal health information if necessary for national security or intelligence activities; and
- To comply with workers’ compensation laws.
DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
1. Except as outlined herein, we will not use or disclose your personal health information unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have already taken action in reliance on the authorization.
2. Ohio law requires that we obtain a consent from you in many instances before disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition; before disclosing information about drug or alcohol treatment you have receiver in a drug or alcohol treatment program; before disclosing information about mental health services you may have received; and before disclosing certain information to the State Long-Term Care Ombudsman. For full information on when such consents may be necessary, you can contact Roberta June Guibord D.O., Inc. at 900 W. So. Boundary St. 3B, Perrysburg Ohio 43551.
II. RIGHTS THAT YOU HAVE
ACCESS TO YOUR PERSONAL HEALTH INFORMATION. Most of the time, you have the right to copy and/or inspect much of the personal health information that we retain on your behalf. You may be charged a reasonable fee for the retrieval and duplication of your health information. All requests for access must be made in writing and signed by you or your legally authorized representative. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons why and explain how you can have the denial reviewed.
B. THE RIGHT TO CORRECT OR UPDATE YOUR PERSONAL HEALTH INFORMATION. You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We will give each request careful consideration; but we are not obligated to make all requested amendments. In order to be considered by us, all amendment requests must be in writing, signed by you or your legally authorized representative, must state the reason for the amendment/correction request, and must be directed to Roberta June Guibord D.O., Inc. 900 W. So. Boundary St. Perrysburg Ohio 43551.
If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.
C. ACCOUNTING FOR DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION. You have the right to receive an accounting of certain disclosures made by us of your personal health information. Requests must be made in writing and signed by you or your legally authorized representative. Accounting request forms are available from Roberta June Guibord D.O., Inc. You may be charged a fee for each accounting you request.
D.RESTRICTIONS ON USE AND DISCLOSURE OF YOUR PERSONAL HEALTH INFORMATION.There are certain uses and disclosures that we make that you have the right to request restrictions on as they relate to treatment, payment, or health care operation. A restriction must be submitted in writing and addressed to Roberta June Guibord D.O., Inc. 900 W. So. Boundary St. 3B. Perrysburg Ohio 43551. We will give each request careful consideration, but we are not obligated to agree to it. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate and we will notify you of such termination. You also have the right to terminate, in writing, any agree-to restriction by sending such termination notice to Roberta June Guibord D.O., Inc. 900 W. So. Boundary St. 3B, Perrysburg Ohio 43551.
E. QUESTIONS/COMPLAINTS. If you have questions, you may contact us at (419)872-5556. As a patient, you retain the right to obtain a paper copy of this Notice of Privacy Practices. If you believe your privacy rights have been violated, you can file a written complaint with Roberta June Guibord D.O., Inc., 900 W. So. Boundary St. 3B, Perrysburg Ohio 43551. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
EFFECTIVE DATE JANUARY 1,2012