Smith
Clinic/Marion Area Health Center
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
Revised: March
2010
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AS WELL AS HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This notice will tell you how we may use
and disclose protected health information about you. Protected health information means any health
information about you that identifies you or for which there is a reasonable
basis to believe the information can be used to identify you. In this notice, we call all of that protected
health information, “medical information.”
This notice also will tell you about your
rights and our duties with respect to medical information about you. In addition, it will tell you how to complain
to us if you believe we have violated your privacy rights.
Who Is Bound By This Notice?
This Notice of Privacy Practices describes
the practices of Smith Clinic, Marion Area Health Center (MAHC), Marion
Ancillary Services, Marion Regional Imaging, Marion Regional Pathology,
MedCenter Anesthesia, and MedCenter Pharmacy.
This notice applies to the following
delivery sites in Marion, OH 43302: 1040 Delaware Avenue; 1050 Delaware Ave; 1025 Harding Memorial Parkway; 1035 Harding
Memorial Parkway; 1073 Harding Memorial Parkway; 980 S. Prospect St. Suites 1,
2, & 3; and 1075 East Center St. The notice also applies to delivery sites
in Delaware, OH 43015: 6 Lexington
Boulevard and 12 Lexington Blvd, as well as 651 W. Marion Rd., Mount Gilead, OH
43338.
How We May Use and Disclose Medical Information About
You.
We will share medical information about
you with each other as necessary to carry out treatment, payment, or our health
care operations.
We use and disclose medical information
about you for a number of different purposes. Each of those purposes is
described below.
• For
Treatment.
We may
use medical information about you to provide, coordinate or manage your health
care and related services by both us and other health care providers. We may disclose medical information about you
to doctors, nurses, hospitals and other health facilities who become involved
in your care. We may consult with other
health care providers concerning you and as part of the consultation share your
medical information with them.
Similarly, we may refer you to another health care provider and as part
of the referral share medical information about you with that provider. For example, we may conclude you need to
receive services from a physician with a particular specialty. When we refer you to that physician, we also
will contact that physician’s office and provide medical information about you
to them so they have information they need to provide services for you.
• For
Payment.
We may use and disclose medical
information about you so we can be paid for the services we provide to
you. This can include billing you, your
insurance company, or a third party payer.
For example, we may need to give your insurance company information
about the health care services we provide to you so your insurance company will
pay us for those services or reimburse you for amounts you have paid. We also may need to provide your insurance
company or a government program, such as Medicare or Medicaid, with information
about your medical condition and the health care you need to receive to obtain
determine if you are covered by that insurance or program.
• For
Health Care Operations.
We may use and disclose medical information
about you for our own health care operations.
These are necessary for us to operate Smith Clinic/MAHC and to maintain
quality health care for our patients.
For example, we may use medical information about you to review the
services we provide and the performance of our employees in caring for
you. We may disclose medical information
about you to train our staff, volunteers and students working in Smith Clinic/MAHC. We also may use the information to study ways
to more efficiently manage our organization.
• How
We Will Contact You.
Unless you tell us otherwise in writing,
we may contact you by either telephone or by mail at either your home or your
workplace. At either location, we may
leave messages for you on the answering machine or voice mail. If you want to request that we communicate to
you in a certain way or at a certain location, see “Right to Receive Confidential
Communications” on page 5 of this Notice.
• Appointment
Reminders.
We may use and disclose medical
information about you to contact you to remind you of an appointment you have
with us.
• Treatment
Alternatives.
We may use and disclose medical
information about you to contact you about treatment alternatives that may be
of interest to you.
• Health
Related Benefits and Services.
We may use and disclose medical
information about you to contact you about health-related benefits and services
that may be of interest to you.
• Marketing
Communications.
We may use and disclose medical
information about you to communicate with you about a product or service to
encourage you to purchase the product or service. This may be:
•To describe a health-related product or service that
is provided by us;
•For your treatment;
•For case management or care coordination for you;
•To direct or recommend alternative treatments,
therapies, health care providers, or settings of care.
We may communicate to you about products
and services in a face-to-face communication by us to you. We also may
communicate about products or services in the form of a promotional gift of
nominal value.
All other use and disclosure of medical
information about you by us to make a communication about a product or service
to encourage the purchase or use of a product or service will be done only with
your written authorization.
• Fundraising.
We may use and disclose medical
information about you to contact you to raise funds for Smith Clinic/MAHC. We may disclose medical information to a
business associate of Smith Clinic/MAHC or a foundation related to Smith Clinic/MAHC
so that business associate or foundation may contact you to raise money for the
benefit of Smith Clinic. We will only
release demographic information, such as your name and address, and the dates
you received treatment or services from Smith Clinic/MAHC. If you do not want Smith Clinic/MAHC or its
foundation to contact you for fundraising, you must notify Smith Clinic, Attn: Privacy Officer, 1040 Delaware Avenue,
Marion, OH 43302 in writing.
• Smith
Clinic Directory.
We may include your name, your location in
our facility, your condition described in general terms, and your religious
affiliation in our directory while you are a patient in our facility. This information, except for your religious
affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to
members of the clergy, such as a minister, priest or rabbi, who ask for you by
name. If you do not want included in our
facility directory, or you want to restrict the information we include in the
directory, you must notify Smith Clinic, Attn:
Privacy Officer, 1040 Delaware Avenue, Marion, OH 43302 of your
objection.
• Individuals
Involved in Your Care.
We may disclose to a family member, other
relative, a close personal friend, or any other person identified by you,
medical information about you that is directly relevant to that person’s
involvement with your care or payment related to your care. We also may use or disclose medical
information about you to notify, or assist in notifying, those persons of your
location, general condition, or death.
If there is a family member, other relative, or close personal friend
that you do not want use to disclose medical information about you to, please
notify Smith Clinic, Attn: Privacy
Officer, 1040 Delaware Avenue, Marion, OH 43302 or tell our staff member who is
providing care to you.
• Disaster
Relief.
We may use or disclose medical information
about you to a public or private entity authorized by law or by its charter to
assist in disaster relief efforts. This
will be done to coordinate with those entities in notifying a family member,
other relative, close personal friend, or other person identified by you of
your location, general condition or death.
• Required
by Law.
We may use or disclose medical information
about you when we are required to do so by law.
• Public Health Activities.
We may
disclose medical information about you for public health activities and
purposes. This includes reporting medical
information to a public health authority that is authorized by law to collect
or receive the information for purposes of preventing or controlling
disease. Or, one that is authorized to
receive reports of child abuse and neglect.
It also includes reporting for purposes of activities related to the
quality, safety or effectiveness of a United States Food and Drug
administration regulated product or activity.
• Victims
of Abuse, Neglect or Domestic Violence.
We may disclose medical information about
you to a government authority authorized by law to receive reports of abuse,
neglect, or domestic violence, if we believe you are a victim of abuse,
neglect, or domestic violence. This will
occur to the extent the disclosure is: (a) required by law; (b) agreed to by
you; or, (c) authorized by law and we believe the disclosure is necessary to
prevent serious harm to you or to other potential victims, or, if you are
incapacitated and certain other conditions are met, a law enforcement or other
public official represents that immediate enforcement activity depends on the
disclosure.
• Health
Oversight Activities.
We may disclose medical information about
you to a health oversight agency for activities authorized by law, including
audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are
necessary for appropriate oversight of the health care system, government
benefit programs, and entities subject to various government regulations.
• Judicial
and Administrative Proceedings.
We may disclose medical information about
you in the course of any judicial or administrative proceeding in response to
an order of the court or administrative tribunal. We also may disclose medical information about
you in response to a subpoena, discovery request, or other legal process but
only if efforts have been made to tell you about the request or to obtain an
order protecting the information to be disclosed.
• Disclosures
for Law Enforcement Purposes.
We may disclose medical information about
you to a law enforcement official for law enforcement purposes:
a. As
required by law.
a. In
response to a court, grand jury or administrative order, warrant or subpoena.
b. To identify or locate a suspect,
fugitive, material witness or missing person.
c. About an actual or suspected victim of
a crime and that person agrees to the disclosure. If we are unable to obtain that person’s
agreement, in limited circumstances, the information may still be disclosed.
d. To alert law enforcement officials to a
death if we suspect the death may have resulted from criminal conduct.
e. About crimes that occur at our
facility.
f. To report a crime in emergency
circumstances.
• Coroners
and Medical Examiners.
We may disclose medical information about you
to a coroner or medical examiner for purposes such as identifying a deceased
person and determining cause of death.
• Funeral
Directors.
We may disclose medical information about
you to funeral directors as necessary for them to carry out their duties.
• Organ,
Eye or Tissue Donation.
To facilitate organ, eye or tissue
donation and transplantation, we may disclose medical information about you to
organ procurement organizations or other entities engaged in the procurement,
banking or transplantation of organs, eyes or tissue.
• Research.
Under certain circumstances, we may use or disclose
medical information about you for research.
Before we disclose medical information for research, the research will
have been approved through an approval process that evaluates the needs of the
research project with your needs for privacy of your medical information. We may, however, disclose medical information
about you to a person who is preparing to conduct research to permit them to
prepare for the project, but no medical information will leave Smith Clinic/MAHC
during that person’s review of the information.
• To
Avert Serious Threat to Health or Safety.
We may use or disclose protected health
information about you if we believe the use or disclosure is necessary to
prevent or lessen a serious or imminent threat to the health or safety of a
person or the public. We also may
release information about you if we believe the disclosure is necessary for law
enforcement authorities to identify or apprehend an individual who admitted
participation in a violent crime or who is an escapee from a correctional
institution or from lawful custody.
• Military.
If you are a member of the Armed Forces,
we may use and disclose medical information about you for activities deemed
necessary by the appropriate military command authorities to assure the proper
execution of the military mission. We
may also release information about foreign military personnel to the
appropriate foreign military authority for the same purposes.
• National
Security and Intelligence.
We may disclose medical information about
you to authorized federal officials for the conduct of intelligence,
counter-intelligence, and other national security activities authorized by law.
• Protective
Services for the President.
We may disclose medical information about
you to authorized federal officials so they can provide protection to the
President of the
• Security
Clearances.
We may use medical information about you
to make medical suitability determinations and may disclose the results to
officials in the United States Department of State for purposes of a required
security clearance or service abroad.
• Inmates;
Persons in Custody.
We may disclose medical information about
you to a correctional institution or law enforcement official having custody of
you. The disclosure will be made if the
disclosure is necessary: (a) to provide health care to you; (b) for the health
and safety of others; or, (c) the safety, security and good order of the
correctional institution.
• Workers
Compensation.
We may disclose medical information about
you to the extent necessary to comply with workers’ compensation and similar
laws that provide benefits for work-related injuries or illness without regard
to fault.
• Mental Health or Chemical Dependency
Records.
If we receive health information about you from a
health care provider, we will not re-disclose or otherwise reveal any mental
health or chemical dependency records contained in that information, beyond the
purpose of the disclosure to us, without first obtaining your written
authorization or as required by law.
• Other
Uses and Disclosures.
Other uses and disclosures will be made
only with your written authorization.
You may revoke such an authorization at any time by notifying Smith
Clinic, Attn: Privacy Officer, 1040
Delaware Avenue, Marion, OH 43302 in writing of your desire to revoke it. However, if you revoke such an authorization,
it will not have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Medical Information About
You.
You
have the following rights with respect to medical information that we maintain
about you.
• Right
to Request Restrictions.
You have the right to request that we
restrict the uses or disclosures of medical information about you to carry out
treatment, payment, or health care operations.
You also have the right to request that we restrict the uses or
disclosures we make to: (a) a family member, other relative, a close personal
friend or any other person identified by you; or, (b) for to public or private
entities for disaster relief efforts.
For example, you could ask that we not disclose medical information about
you to your brother or sister.
To request a restriction, you may do so at
any time. If you request a restriction , you should do so to Smith Clinic, Attn: Privacy Officer, 1040 Delaware Avenue,
Marion, OH 43302 and tell us: (a) what information you want to limit; (b)
whether you want to limit use or disclosure or both; and, (c) to whom you want
the limits to apply (for example, disclosures to your spouse).
We
are not required to agree to any requested restriction. However, if we
do agree, we will follow that restriction unless the information is needed to
provide emergency treatment. Even if we
agree to a restriction, either you or we can later terminate the restriction.
• Right
to Receive Confidential Communications.
You have the right to request that we
communicate medical information about you to you in a certain way or at a
certain location. For example, you can ask that we only contact you by mail or
at work. We will not require you to tell
us why you are asking for the confidential communication.
If you want to request confidential
communication, you must do so in writing to Smith Clinic, Attn: Privacy Officer, 1040 Delaware Avenue,
Marion, OH 43302. Your request must
state how or where you can be contacted.
We will accommodate your request. However, we may, when appropriate, require
information from you concerning how payment will be handled. We also may
require an alternate address or other method to contact you.
• Right
to Inspect and Copy.
With a few very limited exceptions, such
as psychotherapy notes, you have the right to inspect and obtain a copy of
medical information about you.
To inspect or copy medical information
about you, you must submit your request in writing to Smith Clinic, Privacy
Officer, 1040 Delaware Avenue, Marion, OH 43302. Your request should state
specifically what medical information you want to inspect or copy. If you request a copy of the information, we
may charge a fee for the costs of copying and, if you ask that it be mailed to
you, the cost of mailing.
We will act on your request within thirty
(30) calendar days after we receive your request. If we grant your request, in whole or in
part, we will inform you of our acceptance of your request and provide access
and copies.
We may deny your request to inspect and copy medical information if the
medical information involved is information compiled in anticipation of, or use
in, a civil, criminal or administrative action or proceeding. We also may deny your request for certain
other reasons. These include if a
practitioner who has treated you determines, for clearly stated treatment
reasons, that disclosure of the requested record is likely to have an adverse
effect on you.
If we deny your request, we will
inform you of the basis for the denial, how you may have our denial reviewed,
and how you may complain. If you request
a review of our denial, it will be conducted by a licensed health care
professional designated by us who was not directly involved in the denial. We will comply with the outcome of that
review.
• Right
to Amend.
You have the right to ask us to amend
medical information about you. You have
this right for so long as the medical information is maintained by us.
To request an amendment, you must submit
your request in writing to Smith Clinic, Attn:
Privacy Officer, 1040 Delaware Avenue, Marion, OH 43302. Your request
must state the amendment desired and provide a reason in support of that
amendment.
We will act on your request within sixty
(60) calendar days after we receive your request. If we grant your request, in whole or in
part, we will inform you of our acceptance of your request and provide access
and copying.
If we grant the request, in whole or in
part, we will seek your identification of and agreement to share the amendment
with relevant other persons. We also
will make the appropriate amendment to the medical information by appending or
otherwise providing a link to the amendment.
We may deny your request to amend medical
information about you. We may deny your
request if it is not in writing and does not provide a reason in support of the
amendment. In addition, we may deny your
request to amend medical information if we determine that the information:
a. Was not created by us, unless the
person or entity that created the information is no longer available to act on
the requested amendment;
b. Is not part of the medical information
maintained by us;
c. Would not be available for you to
inspect or copy; or,
d. Is accurate and complete.
If we deny your request, we will inform
you of the basis for the denial. You
will have the right to submit a statement of disagreeing with our denial. Your statement may not exceed 2 pages. We may prepare a rebuttal to that
statement. Your request for amendment,
our denial of the request, your statement of disagreement, if any, and our
rebuttal, if any, will then be appended to the medical information involved or
otherwise linked to it. All of that will
then be included with any subsequent disclosure of the information, or, at our
election, we may include a summary of any of that information.
If you do not submit a statement of
disagreement, you may ask that we include your request for amendment and our
denial with any future disclosures of the information. We will include your
request for amendment and our denial (or a summary of that information) with
any subsequent disclosure of the medical information involved.
You
also will have the right to complain about our denial of your request.
• Right
to an Accounting of Disclosures.
You have the right to receive an
accounting of disclosures of medical information about you. The accounting may be for up to six (6) years
prior to the date on which you request the accounting but not before
Certain
types of disclosures are not included in such an accounting:
a. Disclosures to carry out treatment,
payment and health care operations;
b. Disclosures of your medical information
made to you;
c. Disclosures that are incident to
another use or disclosure;
d. Disclosures that you have authorized;
e. Disclosures for our facility directory
or to persons involved in your care;
f. Disclosures for disaster relief
purposes;
g. Disclosures for national security or
intelligence purposes;
h. Disclosures to correctional institutions
or law enforcement officials having custody of you;
i. Disclosures that are part of a limited
data set for purposes of research, public health, or health care operations (a
limited data set is where things that would directly identify you have been
removed.
j. Disclosures made prior to
Under certain circumstances your right to
an accounting of disclosures to a law enforcement official or a health
oversight agency may be suspended.
Should you request an accounting during the period of time you right is
suspended, the accounting would not include the disclosure or disclosures to a
law enforcement official or to a health oversight agency.
To request an accounting of disclosures,
you must submit your request in writing to Smith Clinic, Attn: Privacy Officer, 1040 Delaware Avenue,
Marion, OH 43302. Your request must state a time period for the
disclosures. It may not be longer than
six (6) years from the date we receive your request and my not include dates
before
Usually, we will act on your request
within sixty (60) calendar days after we receive your request. Within that time, we will either provide the
accounting of disclosures to you or give you a written statement of when we
will provide the accounting and why the delay is necessary.
There is no charge for the first
accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you
for the cost of providing the list. If
there will be a charge, we will notify you of the cost involved and give you an
opportunity to withdraw or modify your request to avoid or reduce the fee.
• Right
to Copy of this Notice.
You have the right to obtain a paper copy
of our Notice of Privacy Practices. You
may obtain a paper copy even though you agreed to receive the notice
electronically. You may request a copy
of our Notice of Privacy Practices at any time.
You may obtain a copy of our Notice of
Privacy Practices over the Internet at our web site, www.smithclinic.com
To obtain a paper copy of this notice,
contact: Smith Clinic, Attn: Privacy
Officer, 1040 Delaware Avenue, Marion, OH 43302.
Our Duties
• Generally.
We are required by law to maintain the
privacy of medical information about you and to provide individuals with notice
of our legal duties and privacy practices with respect to medical information.
We are required to abide by the terms of
our Notice of Privacy Practices in effect at the time.
• Our
Right to Change Notice of Privacy Practices.
We reserve the right to change this Notice
of Privacy Practices. We reserve the right to make the new notice’s provisions
effective for all medical information that we maintain, including that created
or received by us prior to the effective date of the new notice.
• Availability
of Notice of Privacy Practices.
A copy of our current Notice of Privacy
Practices will be posted at the registration desk. A copy of the current notice also will be
posted on our web site, www.smithclinic.com.
At any time, you may obtain a copy of the
current Notice of Privacy Practices by contacting Smith Clinic, Attn: Privacy Officer, 1040 Delaware Avenue,
Marion, OH 43302.
• Effective
Date of Notice.
The
effective date of the notice will be stated on the first page of the notice.
• Complaints.
You may complain to us and to the United
States Secretary of Health and Human Services if you believe your privacy
rights have been violated by us.
To file a complaint with us, contact Smith
Clinic, Attn: Privacy Officer, 1040
Delaware Avenue, Marion, OH 43302. All
complaints should be submitted in writing.
To file a complaint with the United States
Secretary of Health and Human Services, send your complaint to him or her in
care of: Office for Civil Rights, U.S. Department of Health and Human Services,
You will not be retaliated against for
filing a complaint.
• Questions
and Information.
If you have any questions or want more
information concerning this Notice of Privacy Practices, please contact Smith
Clinic, Attn: Privacy Officer, 1040
Delaware Avenue, Marion, OH 43302.