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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO
YOUR IDENTIFIABLE HEALTH INFORMATION.
A. OUR COMMITMENT TO YOUR PRIVACY.
Our organization is dedicated to maintaining the privacy of your
identifiable health information. In conduction our business, we will
created records regarding you and the treatment and services we
provide to you. We are required by law to maintain the confidentiality
of health information that identifies you. We also are required by law
to provide you with this notice of our legal duties and privacy
practices concerning your identifiable health information. By law, we
must follow the terms of privacy practices that we have in effect at
the time.
To summarize, this notice provides you with the following information:
• How we may use and disclose your identifiable health information.
• Your privacy rights in your identifiable health information.
• Our obligations concerning the use and disclosure of your
identifiable health information.
The terms of this notice apply to all records containing your
identifiable health information that are created or retained by our
practice. We reserve the right to revise or amend our notice of
privacy practices. Any revision or amendment to this notice will be
effective for all of your records our practice has created or
maintained in the past, and for any of your records we may create or
maintain in the future. Our organization will post a copy of our
current notice in our offices in a prominent location.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Compliance Officer 513-573-9625 or at 7537 Easy Street, Mason, Ohio
45040
C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE
FOLLOWING WAYS.
The following categories describe the different ways in which we may
use and disclose your identifiable health information.
1. Treatment. Our organization may use your identifiable health
information to treat you. Many of the people who work for our
organization may use or disclose your identifiable health information
in order to treat you or to assist others in your treatment.
Additionally, we may disclose your identifiable health information to
others who may assist in your care, such as your physician,
therapists, spouse, children, or parents.
2. Payment. Our organization may use and disclose your
identifiable health information in order to bill and collect payment
for the services and items you may receive from us. For example, we
may contact your health insurer to certify that you are eligible for
benefits (and for what range of benefits) and we may provide your
insurer with details regarding your treatment to determine if your
insurer will cover, or pay for, your treatment. We also may use and
disclose your identifiable health information to obtain payment from
third parties that may be responsible for such costs, such as family
members. Also, we may use your identifiable health information to bill
you directly for services and items.
3. Health Care Operations. Our organization may use and
disclose your identifiable health information to operate our business.
As examples of the ways in which we may use and disclose your
information for our operations, our organization may use your health
information to evaluate the quality of care you receive from use or to
conduct cost-management and business planning activities for our
practice.
4. Appointment Reminders. Our organization may use and disclose
your identifiable health information to contact you and remind you of
visits/deliveries.
5. Health-Related Benefits and Services. Our organization may
use and disclose your identifiable health information to inform you of
health related benefits or services that may be of interest to you.
6. Release of Information to Family/Friends. Our organization
may release your identifiable health information to a friend or family
member that is helping you pay for your health care, or who assist in
taking care of you.
7. Disclosures Required By Law. Our organization will use and
disclose your identifiable health information when we are required to
do so by federal, state, or local law.
D. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the following rights regarding the identifiable health
information that we maintain about you:
1. Confidential Communications. You have the right to request
that our organization communicate with you about your health and
related issues in a particular manner or at a certain location. For
instance, you may ask that we contact you at home, rather than work.
In order to request a type of confidential communication you must make
a written request to Compliance Officer, Dabe Medical, 7537 Easy
Street, Mason, Ohio 45040, specifying the requested method or the
location where you wish to be contacted. Our organization will
accommodate reasonable requests. You do not need to give a reason for
your request.
2. Requesting Restrictions. You have the right to request a
restriction in our use or disclosure of your identifiable information
for treatment payment or health operations. Additionally, you have the
right to request that we limit our disclosure of your identifiable
health information to individuals involved in your care or the payment
for your care, such as family members and friends. We are not required
to agree to your request; however, if we do agree, we are bound by our
agreement except when otherwise required by law, in emergencies, or
when the information is necessary for treatment purposes. In order to
request a restriction in our use or disclosure of your identifiable
health information, you must make your request in writing to
Compliance Officer, Dabe Medical, 7537 Easy Street, Mason, Ohio,
45040. Your request must describe in a clear and concise fashion: (a)
the information you wish restricted; (b) whether you are requesting to
limit our practice’s use, disclosure or both; and (c) to whom you want
the limits to apply.
3. Inspection and Copies. You have the right to inspect and
obtain a copy of the identifiable health information that may be used
to make a decision about, including patient medical records and
billing records, but not including psychotherapy notes. You must
submit your request in writing to Compliance Officer, Dabe Medical,
7537 Easy Street, Mason, Ohio, 45040 in order to inspect and/or obtain
a copy of your identifiable health information. Our organization may
charge a fee for the costs of copying, mailing, labor, and supplies
associated with your request. Our practice may deny your request to
inspect and/or copy in certain limited circumstances; however, you may
request a review of our denial. Another licensed health care
professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information
if you believe it is incorrect or incomplete, and you may request an
amendment for as long as information is kept by or for our
organization. To request an amendment, you request must be made in
writing and submitted to Compliance Officer, Dabe Medical, 7537 Easy
Street, Mason, Ohio, 45040. You must provide us with a reason that
supports your request for amendment. Our organization will deny your
request if you fail to submit your request (and the reason supporting
your request) in writing. Also, we may deny your request if you ask us
to amend information that is: (a) accurate and complete; (b) not part
of the identifiable health information kept by or for the
organization; (c) not part of the identifiable health information
which you would be permitted to inspect and copy; or (d) not created
by our organization, unless the individual or entity that created the
inform not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to
request an “accounting of disclosures.” An “accounting of disclosures”
is a list of certain disclosures our organization has made of your
identifiable health information. In order to obtain an “accounting of
disclosures”, you must submit your request in writing to Compliance
Officer, Dabe Medical, 7537 Easy Street, Mason, Ohio, 45040. All
requests for an “accounting of disclosures” must state the period that
may not be longer than six months and may not include dates before
April 14, 2003. The first list you request within a 12-month period is
free of charge, but our practice may charge you for additional lists
with the same 12-month period. Our organization will notify you of the
costs involved with additional requests and you may withdraw your
request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to
receive a paper copy of our notice of privacy practices. You may ask
us to give you a copy of this notice at any time. To obtain a paper
copy of this notice, contact: Dabe Medical 513-573-9625
7. Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with our
organization or with the Secretary, Department of Health and Human
Services. To file a complaint with our organization, contact: Kim Dabe,
Compliance Officer, Dabe Medical, 7537 Easy Street, Mason, Ohio, 45040
or call 513-573-9625. You will not be penalized for filing a
complaint. You also have the right to file a complaint with the Joint
Commission by contacting them at 1-800-994-6610.
8. Right to Provide an Authorization for Other Uses and Disclosures.
Our organization will obtain your written authorization for uses and
disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provided to us regarding the use
and disclosure of your identifiable health information may be revoked
at any time in writing. After you revoke your authorization, we will
no longer use or disclose your identifiable health information for
reasons described in the authorization. Please note we are required to
retain records for your care.
THIS NOTICE IS EFFECTIVE AS OF APRIL 14, 2003
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