Privacy Notice

Notice of Privacy Practices

Form 7.20

This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review carefully.

 Protected health information (PHI), about you, is maintained as a record of your contacts or visits for healthcare services with our practice.  Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment.  This Notice describes your rights to access and control your PHI.  It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

If you have any questions about this Notice, please contact our Privacy Manager at (330) 668-6766.

Your Rights Under The Privacy Rule

Following is a statement of your rights, under the Privacy Rule, in reference to your PHI.  Please feel free to discuss any questions with our staff.

  • You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices – We are required to follow the terms of this notice.  We reserve the right to change the terms of our notice, at any time.  If needed, new versions of this notice will be effective for all PHI that we maintain at that time.  Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.  The Notice will also be posted in a conspicuous place within the practice, and if such is maintained by the practice, on it’s web site.
  • You have the right to authorize other use and disclosure This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice.  For example, we would need your authorization to use or disclose your PHI for marketing purposes or for any use or disclosure of psychotherapy notes.  You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.
  • You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using a method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you.  We will follow all reasonable requests.  You must inform us in writing how you wish to be contacted (using a form provided by our practice).
  • You have the right to inspect and copy your PHI This means you may inspect and obtain a copy of PHI about you that is contained in your patient record.  If your health record is maintained electronically, you will also have the right to request a copy in electronic format.  We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.
  • You have the right to request a restriction of your PHI This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.  If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment.  In certain cases, we may deny your request for a restriction.  You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket.  We are not permitted to deny this specific type of requested restriction.
  • You may have the right to request an amendment to your protected health information This means you may request an amendment of your protected health information for as long as we maintain this information.  In certain cases, we may deny your request for an amendment.
  • You have the right to request a disclosure accountabilityThis means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office.

How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health information that we are permitted to make.  These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

  • Treatment We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services.  This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment.  For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions.  We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.
  • Payment Your PHI will be used, as needed, to obtain payment for your healthcare services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.
  • Healthcare Operations We may use or disclose, as needed, your PHI in order to support the business activities of our practice.  This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions.
  • Regional Information Organization – The practice may elect to use a regional information organization or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.Other Permitted and Required Uses and Disclosures