Effective Date: September 23, 2013
Notice of Privacy Practices of
GCGA PHYSICIANS, INC. d/b/a OHIO GASTROENTEROLOGY & LIVER INSTITUTE
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.
CONTACT PERSON: If you have any questions about this notice, please contact our Privacy Officer at 2925 Vernon Place, Cincinnati, OH 45219. Telephone 513-751-6667; Fax 513-872-4553; email email@example.com.
WHO WILL FOLLOW THIS NOTICE
- Any health care professional authorized to enter information into your medical chart.
- Any member of a volunteer group we allow to help you while you are our patient.
- All employees, staff and other professional personnel of the Ohio Gastroenterology & Liver Institute.
- The persons listed above may share your medical information with each other for the treatment, payment or heath care operation purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Ohio Gastroenterology & Liver Institute. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or maintained by us, whether made by our personnel or other health care providers.
We are required by law to: (1) make sure that medical information that identifies you is kept private; (2) give you this notice of our legal duties and privacy practices with respect to medical information about you; (3) notify you in the event of a breach of your unsecured medical information; and (4) follow the terms of the notice that are currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and will provide some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
- For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other health care personnel who are involved in taking care of you at the Ohio Gastroenterology & Liver Institute. For example, a physician who may be treating you for a digestive disorder will need to know if you have previously been diagnosed with an ulcer. We also may disclose medical information about you to people outside the Ohio Gastroenterology & Liver Institute who may be involved in your medical care such as referring doctors, family members, clergy or others we use to provide services that are part of your care.
- For Payment. We may use and disclose medical information about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about any treatment you receive so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, authorization, or to determine whether your health plan will cover the treatment.
- For Health Care Operations. We may use and disclose medical information about you for our administrative operations. These uses and disclosures are necessary to run the Ohio Gastroenterology & Liver Institute and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many of our patients to decide what additional services the Ohio Gastroenterology & Liver Institute should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other health care personnel for review and learning purposes. We may also combine the medical information we have with medical information from other organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
- Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition if you are hospitalized. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
WAYS WE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION WITHOUT YOUR AUTHORIZATION:
- As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
- Victim of Abuse, Neglect or Domestic Violence. We may use and disclose medical information about you if we reasonably believe you to be a victim of abuse, neglect, or domestic violence to the extent the disclosure is required by law and complies with (and is limited to) the relevant requirements of such law.
- To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
- Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
- Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Public Health Risks. We may disclose medical information about you for public health activities, such as to the Center of Disease Control to prevent or control disease; or, to the Food and Drug Administration to track regulated products.
- Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law Enforcement. We may release medical information if asked to do so by a law enforcement official, in response to a court order, subpoena, warrant, summons or similar process.
- Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
- Organ Donation. If you are an organ or tissue donor, we may use or disclose your protected health information to organizations that handle organ procurement or transplantation — such as an organ donation bank — as necessary to facilitate organ or tissue donation and transplantation.
- National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law, as well as to federal officials who protect the President and other dignitaries.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your medical information to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
- Research. We may use and disclose your medical information for research purposes, but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your medical information. Even without that special approval, we may permit researchers to look at your medical information to help them prepare for research, for example, to allow them to identify patients who may be included in their research project, as long as they do not remove, or take a copy of, any of your medical information. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research. However, we will only disclose the limited data set if we enter into a data use agreement with the recipient who must agree to (1) use the data set only for the purposes for which it was provided, (2) ensure the confidentiality and security of the data, and (3) not identify the information or use it to contact any individual.
WE MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION IN THE FOLLOWING WAYS ONLY WITH YOUR WRITTEN AUTHORIZATION:
- Most uses and disclosures of psychotherapy notes (if applicable to the care you receive from our practice);
- Uses and disclosures of your medical information for marketing purposes; and
- Disclosures that constitute a sale of your medical information.
IF WE CONDUCT FUNDRAISING ACTIVITIES, YOU CAN “OPT OUT” OF RECEIVING MATERIALS:
If we conduct fundraising activities, we may use or disclose your medical information in order to contact you; however, you have the right to “opt out” of receiving fundraising materials. If you do not want to receive these types of materials, please submit a written request to our Privacy Officer.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You acknowledge and understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.
THESE ARE YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION MAINTAINED BY US:
- Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the contact person listed on page one of this notice. If you request a copy of the information, we may charge a reasonable fee for the cost of copying, mailing or other associated supplies. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Ohio Gastroenterology & Liver Institute will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Ohio Gastroenterology & Liver Institute.
To request an amendment, your request must be made in writing and submitted to the contact person listed on page one of this notice. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (i) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (ii) is not part of the medical information kept by or for us; (iii) is not part of the information which you would be permitted to inspect and copy; or (iv) is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we make of medical information about you without your authorization or unrelated to your treatment, payment for your treatment, or our health care operations.
To request this list or accounting of disclosures: You must submit your request in writing to the contact person listed on page one of this notice. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or our health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. Except when you pay “out-of-pocket” as described below, we are not required to agree to your request for restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment
- Right to Request Restrictions when you pay “out-of-pocket”. If you paid out-of-pocket in full for a specific item or service (or in other words, you have requested that we not bill your health plan), you have the right to ask that your medical information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
To request restrictions: You must make your request in writing to the person listed on page one of this notice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications: You must make your request in writing to the person listed on page one of this notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for the medical information we already have about you, as well as any information we receive in the future. We will prominently post a copy of the current notice at our office(s). The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you sign-in for care at our office(s), we will offer you a copy of the current notice then in effect.
COMPLAINTS (You will not be penalized for filing a complaint.)
If you believe your privacy rights have been violated, you may file a complaint. To file a complaint with our practice, please contact the person listed on page one of this notice. Or, you can file a complaint with the Secretary of the Department of Health and Human Services at the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C., 20201. All complaints must be submitted in writing.