The terms of this Notice of Privacy Practices apply to Fairﬁeld Medical Center located at 401 North Ewing Street, Lancaster,Ohio composed of:
• Fairﬁeld Diagnostic Imaging - 1241 River Valley Boulevard, Lancaster
• Fairﬁeld Medical Diagnostic Services at Main Street - 1159 East Main Street, Lancaster
• Fairﬁeld Medical Diagnostic Services at Colonnade - 1550 Sheridan Drive, Suite 302, Lancaster
• Fairﬁeld Medical Diagnostic Services at Granville Pike - 1781 Countryside Drive, Lancaster
• Fairﬁeld Medical Diagnostic Services at Millersport - 12135 Lancaster Street, Millersport
• Ewing Square Specialty Services - 1253 East Main Street, Lancaster
• Fairﬁeld Medical Center Business Oﬃce - 1153 East Main Street, Lancaster
• Fairﬁeld Medical Diagnostic Services at River Valley - 1203B River Valley Boulevard, Lancaster
• Fairﬁeld Medical Diagnostic Services at River View - 2405 North Columbus Street, Suite 180, Lancaster
• Outpatient Therapy Services/SportsClinic & Worklife - 1143 East Main Street, Lancaster
• River View Surgery Center - 2405 North Columbus Street, Lancaster
• Southeast Ohio Sleep Disorders Center - 135 North Ewing Street, Lancaster
• Surgery Pavilion - 135 North Ewing Street, Lancaster
• Wound Clinic - 135 North Ewing Street, Lancaster
• The physicians and other licensed professionals seeing and treating patients at Fairﬁeld Medical Center and it’s associates.
The members of this clinically integrated health care arrangement work and practice at Fairﬁeld Medical Center with reasonable speciﬁcity the service delivery sites involved in the organized health care arrangement. All of the entities and persons listed will share personal health information of our patients as necessary to carry out treatment, payment, and health care 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 on the authorization. There are certain uses and disclosures of your personal health information for which we will always obtain a prior authorization, and these 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 that may include procedures, medications, tests, etc. We may also release your personal health information to another health care 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 health care, 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 or to the person responsible for your payment.
Uses and Disclosures For Healthcare Operations. We will use and disclose your personal health information as necessary, and as permitted by law, for our health care 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 may also disclose your personal health information to another health care facility, health care 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.
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 may also 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 certain of your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
Fundraising. We may use certain information (name, address, telephone numbers or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money for Fairﬁeld Medical Center and you will 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 are free to opt out of fundraising solicitation, and 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 check the box on the enclosed printed, pre-addressed and prepaid card and mail in the alternative or you can call our telephone number (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 us, and we will honor your request not to receive any Fairﬁeld Medical Center fundraising communications from us after the date we receive your decision.
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 health care 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 and we retain the right to terminate an agreed-to 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-to restriction by sending such termination notice to the Medical Records Department at Fairﬁeld Medical Center.
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 Privacy Officer at 401 North Ewing Street, Lancaster, Ohio 43130. You may also ﬁle a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. 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) 687-8011. 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.
This Notice of Privacy Practices is revised as of May 6, 2014.