Notice of Privacy Practices

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.

The Notice of Privacy Practices applies to all entities affiliated with Fairfield Medical Center. Entities include, specifically, Fairfield Medical Center and its offsite facilities. Entities also include Fairfield Healthcare Professions, Fairfield Diagnostic Imaging, River View Surgery Center and Fairfield Medical Sleep Lab. Entities also include any future deliver sites established by Fairfield Medical Center or its affiliates.

All of the entities listed above will share personal health information of our patients as necessary to carry out treatment, payment and healthcare 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 your 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 of Privacy Practices as necessary and to make the new notice effective for all personal health information maintained by us. You may receive a copy of any revised notices by submitting a request to the Medical Records Department.

USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Your 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 in writing unless we have taken any action in reliance of the authorization. There are certain uses and disclosures of your personal health information for which we will always obtain a prior authorization, and they include:
Marketing communications, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health or wellness information, or a communication about health- related products or services that we offer or that are directly related to your treatment.
Most sales of your health information, unless for treatment or payment purposes as required by law.
Psychotherapy notes, unless otherwise permitted or required by law.
Uses and Disclosures For Treatment. We will make uses and disclosures of your personal health information as necessary for your treatment. For instance, doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you. Treatment that may include procedures, medications, tests, etc. We also may release your personal health information to another healthcare facility or professional who is not affiliated with our organization but who is or will be providing treatment to you. For instance, if after you leave the hospital, you are going to receive home healthcare, we may release your personal health information to that home health agency so that a plan of care can be prepared for you.

Uses and Disclosures For Payment. We will make uses and disclosures of your personal health information, as necessary, for the payment purposes of those health professionals and facilities that have treated you or provided services to you. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you, or we may use your information to prepare a bill to send to you, the person responsible for your payment, or your insurance company.

Uses and Disclosures For Healthcare Operations. We will use and disclose your personal health information as necessary, and as permitted by law, for our healthcare operations, which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients. We also may disclose your personal health information to another healthcare facility, healthcare professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.

Health Information Exchange (HIE). If a statewide or regional health information exchange operates in this state, Fairfield Medical Center may participate and share your health records electronically with the exchange for the purposes of improving the overall quality of healthcare services provided to you. The HIE would have a duty to implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of your medical information. You may opt in or out of the exchange by contacting the Medical Records department and completing a form to request to restrict your information from being shared with the HIE.

Our Facility Directory. We maintain a facility directory listing your name, room number, general condition and, if you wish, your religious affiliation. Unless you choose to have your information excluded from this directory, the information, excluding your religious affiliation, will be disclosed to anyone who requests it by asking for you by name. This information, including your religious affiliation, may be provided to members of the clergy. You have the right during registration to have your information excluded from this directory and also to restrict what information is provided and/or to whom.

Family and Friends Involved In Your Care. With your approval, 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 of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individuals without your approval. We also may disclose limited 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 that may be involved in some aspect of caring for you.

Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide your personal health information to one or more of these outside persons or organizations who assist us with our healthcare operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information in accordance with our policies and state and federal regulations.

Fundraising. In accordance with federal regulation [45 CFR § 164.501], we may use certain demographic information from your medical record to contact you for the purpose of fundraising for Fairfield Medical Center. You have the right to opt out of receiving such communications with each solicitation. For the same purpose, we may provide your name to our institutionally related foundation. The money raised will be used to expand and improve the services and programs we provide to the community. You have the right to opt out of fundraising solicitation. Your decision will have no impact on your treatment or payment for services at Fairfield Medical Center. If you do not want to receive future fundraising requests supporting Fairfield Medical Center, please contact us at 740-687-8107 or our toll free number 1-800-548-2627 and leave a message identifying yourself and stating that you do not want to receive fundraising requests. There is no requirement that you agree to accept fundraising communication from Fairfield Medical Center. We will honor your request after the date we receive your decision.

Appointments and Services. We may contact you to provide appointment reminders and/or test results. You have the right to request and we will accommodate reasonable request by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders not to be left on voicemail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to the Medical Records Department.

Health Products and Services. We may, from time to time, use your personal health information to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.

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

Confidentiality of Alcohol and Drug Abuse Patient Records. The confidentiality of alcohol and drug abuse patient records maintained by this facility is protected by federal law and regulations. Generally, the facility may not say to a person outside the program that you attend a drug or alcohol program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you consent in writing: (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law and regulations do not protect any information about a crime committed by you either at our facility or against any person who works for the facility or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

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 consent or authorization.
• We may release your personal health information for any purpose required by law.
• We may release your personal health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations.
• We may release your personal health information as required by law if we suspect child abuse or neglect; we also may release your personal health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence.
• We may release immunization records to a student’s school, but only if parents or guardians (or the student if not a minor) either orally or in writing.
• We may release your personal health information to the Food and Drug Administration, if necessary, to report adverse events, product defects, or to participate in product recalls.
• We may release your personal health information to your employer when we have provided healthcare to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer.
• We may release your personal health information, if required by law, to a government oversight agency conducting audits, investigations, or civil or criminal proceedings.
• We may release your personal health information if required to do so by subpoena or discovery request; in some cases you will have notice of such release.
• We may release your personal health information to law enforcement officials, as required by law, to report wounds and injuries and crimes.
• We may release your personal health information to coroners and/or funeral directors consistent with law.
• We may release your personal health information, if necessary, to arrange an organ or tissue donation from you or a transplant for you.
• We may release your personal health information for certain research purposes when such research is approved by an
institutional review board with established rules to ensure privacy.
• We may release your personal health information if in limited instances if we suspect a serious threat to health or safety.
• We may release your personal health information if you are a member of the military, as required by armed forces services. We also may release your personal health information if necessary, for national security or intelligence activities.
• We may release your personal health information to workers’ compensation agencies, if necessary, for your workers’ compensation benefit determination.
• We may use your email address to provide you instructions and login information to access your electronic medical record.

Ohio law requires that we obtain a consent from you in many instances before disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition; before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program; and before disclosing information about mental health services you may have received; and before releasing genetic testing.

RIGHTS THAT YOU HAVE
You have the right to copy and/or inspect much of the personal health information that we retain on your behalf. Requests for access may be made verbally or in writing to the Medical Records Department and require an authorization for release of information signed by you or your legal representative. Usually the records will be released within 30 days of your request.

Fees for copies of medical records will be assessed in accordance with Ohio Revised Code 3701.742.

Chart reviews also will be scheduled with the Medical Records Department and will be charged at $10 (records reviewed within the department). There is no charge for the copying and release of your health information when it is released to another healthcare provider for continuity of care. To request confidential communication in an alternative location/address, please send in a written request to the following address: Medical Records Department, 401 N. Ewing St., Lancaster, Ohio 43130

Amendments to Your Personal Health Information. You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. You will receive an answer to your request within 60 days. 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 for the amendment/correction request. If an amendment or correction to your request is made by us, we also may notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from the Medical Records Department at Fairfield Medical Center.

Accounting for Disclosures of Your Personal Health Information. You have the right to receive an accounting of certain disclosures made by us of your personal health information in the previous six years. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from the Medical Records Department at Fairfield Medical Center. The first accounting in any 12-month period is free; you will be charged a fee of $15 for each subsequent accounting you request within the same 12-month period.

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 healthcare operations. A restriction request form can be obtained from the Medical Records Department at Fairfield Medical Center. In most cases, we are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-upon 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, an agreed-upon restriction by sending such termination notice to the Medical Records Department at Fairfield Medical Center.

If you pay-in-full for a service or healthcare item, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

Breach Notification. In the unlikely event that there is a breach, or unauthorized release of your personal health information, you will receive notice and information on steps you may take to protect yourself from harm.

Complaints. If you believe your privacy rights have been violated, you can file a complaint in writing to the compliance officer at 401 N. Ewing St., Lancaster, Ohio 43130. You may also file a complaint, in writing, within 180 days of a violation of your rights with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Ave. SW, Washington D.C., 20201. You can also call 877-696-6775 or visit www.hhs.gov/ocr/privacy/hipaa/complaints. There will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Notice. You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.

Further Information. If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer at 740-687-8634. As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

Revised Date. This Notice of Privacy Practices is revised as of Oct. 20, 2015.