Protected Health Information (PHI) General Notice

This notice describes how Medical Information about you may be used and disclosed, and how you can access this information. Please read this notice carefully.

This Notice is to be read before you agree to the terms of the “Consent Form”. You must indicate that you have reviewed this notice prior to signing the “Consent Form”.

A Federal Privacy Law (known as the Health Insurance Portability and Accountability Act) was passed by Congress to further increase the information safeguards and security of patient healthcare information. This Notice describes the uses and disclosures of Protected Health Information (PHI). PHI is defined as identifiable health information about you that has been collected by a healthcare provider/ supplier as it relates to your past, present, or future physical or mental health, or condition.

Your consent will be obtained in writing at the start of care or, on the date of delivery of services/medical supplies and equipments, and this will give the provider/ supplier permission to use or disclose your PHI to carry out your treatment, payment, or healthcare operations. All uses and disclosures will only be made with your authorization; this can also be revoked by you. You may also request restrictions on certain uses and disclosures; however we are not required to agree to such a request. PHI may also be disclosed to a client’s personal representative; if under applicable law that person has the authority to act on behalf of a patient. The representative must also be an adult or an emancipated minor. When the provider/ supplier receives or obtain valid authorization for use or disclose of PHI, such a use or disclosure will be consistent with such authorization.

Other uses/ disclosures of PHI will only be made when we receive your written authorization and you may also revoke your authorization. PHI may be used/ disclosed without prior written authorization when 1. There is a indirect treatment relationship 2. Emergency Treatment Situations (unable to obtain prior consent, a consent will be attempted as soon as is reasonably practicable after the delivery of such treatment 3. When required by law (attempted to obtain consent but was unable to do so) 4. Attempted to obtain consent but was unable to do so, because of inability to communication. The attempts to obtain consent and reasons for obtaining will be documented. Consent obtained by another healthcare provider/ supplier will not be utilized unless there was an indirect treatment relationship with the patient, or a joint consent was utilized.

You have the right to receive confidential information and to inspect, copy, amend, receive accounting of PHI disclosures, and to obtain a paper copy of the PHI notice upon request. Access to PHI will be provided only on a need-to-know basis. This means that other employees and business associates will only be given access to PHI when there is a legitimate clinical or business need for information.

If you believe a violation has occurred, you should contact the facility’s/ supplier’s privacy officer at 419-636-2702, or address your complaint to the CEO/ President. You may file a complaint with the Office of Secretary, Department of Health & Human Services, 200 Independence Ave. SW, Washington, DC 20201, or http://www.hhs.gov