MedCentral Health System                                      La versión española
Organized Health Care Arrangement
Notice of Privacy Practices

Effective Date - April 14, 2003

Revised Date - February 17, 2010

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, and maintain it with your important health papers.

Should we make any substantial revisions to this Notice, you will receive a new Notice on the next occasion that you receive services from a MedCentral Health System facility.
The terms of this Notice of Privacy Practices apply to MedCentral Health System operating as a clinically integrated organized health care arrangement composed of Mansfield and Shelby Hospitals, Rapid Response, WorkAble, Pediatric Therapy, MedCentral Home Care / Hospice, PainCare, Express Imaging, Wellness Complex, Outreach Laboratories, MedCentral Professional Association, MedCentral Foundation and the Physicians and other licensed professionals assessing and treating patients at each Hospital and other locations of the System.

The members of this arrangement work and practice at various locations in Richland County. All of the entities and persons listed will share personal health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients' personal health information and to provide patients with notice of our legal duties and privacy practices with respect to their personal health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all personal health information maintained by us.

Authorization

Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization at any time. You must revoke authorization in writing. Revoking authorization does not apply to information used or disclosed prior to the Health system's receipt of your written notice revoking authorization.

Uses and Disclosures for Treatment

With your signed consent for treatment, we will use and disclose your personal health information as necessary for your treatment. Doctors and nurses and other health care professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan your treatment, including procedures, medications, tests and other services. Since your personal health information is vital to providing quality care, without your permission to use your information in this way, the facility and Medical Staff may elect to not provide treatment to you, except in an emergency situation.

Uses and Disclosures for Payment

With your signed consent for treatment, we will make use of and disclose your personal health information as necessary for payment purposes. For instance, we may forward information regarding your medical treatment to your insurance company to obtain approval and arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or to the person responsible for payment for services you received. We may disclose your information to others who have provided care to you for their billing purposes as well. Should you not sign this consent, you will personally be financially responsible for all services you receive.

Uses and Disclosures for HealthCare Operations

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 other matters. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients.

Facility Directory

We maintain a facility directory listing each patient's name, location (i.e. room number), general condition and, if you wish, religious affiliation. A Home Care / Hospice patient's location is considered to be their home, or wherever they are staying. Unless you choose to have your information excluded from the directory, except for your religious affiliation, it will be disclosed to anyone who requests it by asking for you by name. Directory information, including your religious affiliation, may also be disclosed to any member of the clergy without them specifically being required to ask for you by name.

You have the right to have your information excluded from this directory and/or to restrict what information is provided and/or to whom information is provided. Should you prefer exclusion from this directory, you should notify the registration staff at the time of registration, or any health system staff member providing care to you. If you request exclusion from the directory, the health system staff will inform anyone inquiring about you that there is no record of you being a patient with the health system.

Family and Friends involved in your care

We may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment for your care. This is to help that person in caring for you or in arranging payment for your care. If you are unavailable, incapacitated or facing an emergency medical situation, we may determine that a limited disclosure is in your best interest. In this case, we may share limited personal health information with such individuals without your approval or consent. We may also 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 persons who may be involved in some aspect of caring for you.

Business Associates

Certain aspects of our service to you are performed through contracts with outside persons or organizations. These include auditing, accreditation, legal services and other services. At times, it may be necessary for us to provide certain components of your personal health information to one or more of these outside persons or organizations to assist in our health care operations. In all cases, we require these business associates to contract with us that they have appropriate safeguards in place to protect the privacy of your information.

Fundraising / Newsletters

We may contact you to donate to a fundraising effort for or on our behalf. You may also receive newsletters from the health system regarding services and upcoming events. You have the opportunity to "opt-out" of being on the mailing list to receive fundraising materials or other communications from the health system, except those distributed to the entire community. In order to be excluded from the mailing list, please contact (419) 526-8583.

Appointments and Services

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. You have the right to request that we communicate with you by an alternate method or at an alternate location. We will try to accommodate such requests if it is within our capability to do so. For example, you may wish appointment reminders and other messages to not be left on voicemail / message machines, to be called to an alternate phone number or sent to an alternate address. You must request such confidential communication in writing, by sending notice to Financial Customer Service - 335 Glessner Ave., Mansfield, Ohio 44903.

Research

In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a researcher may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board which oversees the research and that limit the use and disclosure of patient information.

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 authorization. We may release your personal health information:

• For public health activities, such as required reporting of disease, injury, birth, death, or any required public health investigations.
• As required by law if we suspect any abuse or neglect of a child or elder, or if we believe you are a victim of abuse, neglect or domestic violence.
• To the U.S. Food and Drug Administration if necessary to report adverse events, product defects or to participate in product recalls.
• To your employer when we have provided health care to you at the request of your employer. In most cases, you will be requested to authorize information to be disclosed to your employer.
• If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.
• To workers' compensation agencies if necessary for your workers' compensation benefit determination.
• If required to do so by a court or administrative order.
• To law enforcement officials as required by law to report wounds and injuries and as related to certain crimes.
• To coroners and/or funeral directors consistent with law.
• If necessary to arrange an authorized organ or tissue donation from you or a transplant for you.
• In limited portions for certain research purposes, when such research is approved by an institutional review board with established rules to ensure privacy, including clinical registries and databases.
• If you are a member of the military as required by armed forces services. We may also release your personal health information if necessary for national security or intelligence activities.
• For any purpose required by law, such as reporting of criminal activities, warning of a threat, etc.
• We may release your personal health information, billing information, contact information and demographic information to others who have provided care for you.

Rights that you have:

Access to your Personal Health Information: You have the right to review and/or obtain a copy of much of the personal health information that we retain on your behalf. We may charge you a specified amount per page if you request a copy of the information. We may also charge for postage if you request a mailed copy and may charge for preparing a summary of the requested information if you request such a summary.

Effective February 17, 2010, you have the right to obtain an electronic copy of your health information that exists in an electronic format and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous and specific with complete name and mailing address or other identifying information.

Amendments to your Personal Health Information: You have the right to request in writing that personal health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments, but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative and must state the reason(s) for the amendment/correction request. If we make the requested changes, we may also notify others who work with us and who have copies of the uncorrected record if we believe such notification is necessary. We may contact the provider who provided the information being amended to determine whether they wish to respond to your request.

Accounting for Disclosure of Personal Health Information: You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free. You may be charged a fee for each subsequent accounting you request within the same 12-month period. Effective January 1, 2014, when you request an accounting of disclosures of your electronic health record, the accounting will be for three years prior to the date of the request for the accounting and will include, in addition to all types of disclosures listed in the general policy, disclosures for treatment, payment and health care operations.

Restrictions on Use and Disclosure of your Personal Health Information: You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment or health care operations. This request must be made in writing. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction.

Complaints: If you believe your privacy rights have been violated, you can file a complaint with us. You may also file a complaint with governmental authorities in writing within 180 days of the violation of your rights. There will be no retaliation in response to the filing of a complaint. Although complaints must be filed in writing, you may contact by telephone if you so choose.

Regional Office for Civil Rights - U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240 Chicago, Ill. 60601
Voice Phone (312)886-2359  FAX (312)886-1807  TDD (312)353-5693

As a patient, you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such a copy by e-mail or other electronic means.

Contact List

To obtain a copy of the Notice: Check the health system website at www.medcentral.org or contact Financial Customer Service at (419) 526-8428 and a copy will be mailed to you.

To "opt out" of contacts from us, or disclosures related to Fund raising purposes: Contact the Public Relations department at (419) 526-8583.

To request removal from marketing mailing lists: Contact the Public Relations department at (419) 526-8583.

To make a request concerning specific methods of contacting you (notices of appointments, instructions, etc.): Contact Financial Customer Service at (419) 526-8428.

For copies or inspection of your Personal Health Information: Contact Medical Records at (419) 526-8138

To request an amendment to your Personal Health Information: Contact Medical Records at (419) 526-8046

For an accounting of disclosures made of your Personal Health Information, other than for treatment, payment or health care operations: Contact Medical Records at (419) 526-8046

To request restrictions or termination of restrictions of disclosures of your Personal Health Information: Contact Medical Records at (419) 526-8046

If you have a complaint or concern regarding violations of your privacy rights: Contact the Privacy Officer at (419) 526-8046

If you have questions or need further assistance regarding this Notice of Privacy Practices: Contact the Privacy Officer at (419) 526-8046

EFFECTIVE DATE: This notice of Privacy Practices is effective April 14, 2003 and revised February 17, 2010. MedCentral Health System reserves the right to change the notice at any time a substantive change is made to policies and procedures, and to make revisions to policies and procedures with minimal impact on the contents of this notice without changing the notice.

Last updated February 9, 2010