Notice of Privacy Practices

Health Insurance Portability and Accountability Act of 1996

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.

If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice.

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

Our Responsibilities

Ohio Head and Neck Surgeons Inc. is required by law to maintain the privacy of your health information, and to provide you with a description of our legal duties and privacy practices regarding your health information. The current Notice will be posted in the main waiting area, and at our website at www.ohioheadandneck.com. The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.

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.

How We May Use and Disclose Medical Information About You

The following categories describe examples of the way we use and disclose medical information:

For 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, a pharmacy or other healthcare provider. We may communicate your information either orally, in writing or by facsimile.

Special Notices: We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You have the right to opt out of such special notices, and each such notice will include instructions for opting out.

For Payment: We may use and disclose your PHI regarding your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you.

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, auditing functions and patient safety activities.

Health Information Organization: The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To others involved in your healthcare: Unless you object, we may disclose PHI about you to a member of your family, a relative, a close friend or any other person that you identify that directly relates to that persons involvement in your healthcare. 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. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death.

Other permitted and Required Uses and Disclosures: We are also permitted to use and disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; national security; workers compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Your Rights Under the Privacy Rule: Although your health record is the physical property of Ohio Head and Neck Surgeons Inc., the 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.

Notice of Privacy Practices: 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. 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 our main waiting area, and on our website.

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 permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you.

Alternative Means of Confidential Communication: You have the right to ask us to contact you about medical matters using an alternative method (example-email or telephone), and to a destination (example-cell phone or alternative address) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

The Right to Inspect and Copy Your PHI: You may inspect, and obtain a copy of your complete health 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.

The Right to Request a Restriction of PHI: You may inspect, and obtain a copy of your complete health 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.

Right to Request an Amendment to PHI: You may request and amendment of your PHI for as long as we maintain this information. In certain cases, we may deny this request.

The Right to Request a Disclosure Accountability: You may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office.

The Right to Receive a Privacy Breach Notice: You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

Privacy Complaints: You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Officer listed at the end of this notice.

We will not retaliate against you for filing a complaint.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Officer Julie Farley, BBA at 330-492-2844.