Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give this Notice about our privacy practices, and our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect the date of your signature and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the
new terms of our Notice effective for all health information that we maintain, including health information we
created or received before we made the changes. Before we make a significant change in our privacy practices, we
will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed in this Notice.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have question or concern, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or location, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the Office for Civil rights. We have provided you with the address to file your complaints with the Office for Civil rights at the end of this section.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with the Privacy Officer or with the Office for Civil Rights.
Privacy Officer: Shelia A. Atkins
Address: 1188 State Route 131 Milford, Ohio 45150
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed in this Notice. There will be no charge to you for such as copies. You may also request access by sending us a letter to the address in this Notice.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years but not before April 14, 2003. If you request this accounting more than once in a 12 month period we may charge you a reasonable, cost based fee for responding to these additional requests.