Please review the following information carefully. This notice describes how medical information about you may be used, disclosed and accessed by you or others.
We understand that information we collect about you and your health is personal. Keeping your health information private is one of our most important responsibilities. We are committed to protecting your health information and following all laws regarding the use of your health information. The law says:
Your private health information may be used by health care providers such as doctors, nurses, therapists and social workers who take care of you. They may need your private health information in order to determine your plan of care. This may cover health care services you had before now, or services you may have later on. We may share health information about you in order to help you get services you may need. We may also use your information to contact you about appointment reminders or to tell you about treatment alternatives.
You may be asked to sign a separate form, called an authorization form, allowing your health care information to go somewhere else if:
The authorization form tells us what, where and to whom the information must be sent.
Your authorization is good for six (6) months or until the date you put on the form. You can cancel or limit the amount of information sent at any time by letting us know in writing.
You may see your health information, unless it is the private notes taken by a mental health provider or it is part of a legal case. Most of the time you can receive a copy if you ask. You may be charged a small amount for the copying costs. If you think some of the information is wrong, you may ask in writing that it be changed or new information be added. You may ask that the changes or new information be sent to others who have received your health information from us. You may ask for a list of any places where health information may have been sent, unless it was sent for treatment, for payment, for checking to make sure you receive quality care, or to make sure the laws are being followed.
Bills might be sent to Medicare, Ohio Medicaid, or BCMH. The bill has information about what services you had.
When private health information is released with Authorization, it is normally used to support Treatment or Payment of medical situations or it may be released for the use of Medicaid Operations. The release of health information for this purpose is not tracked or accountable to you, the patient/recipient (HIPAA rule 164.506). Any other release made without your authorization is tracked and is accountable. We
always report:
This notice is yours. If we change anything in this notice, you will get a new notice during your next visit to our office.
To find out if your health information has been released without your authorization for purposes other than Treatment, Payment or Operations, you may call the Privacy Officer and ask for a “Request for Accounting for Disclosures” form. Fill out and return it to
If you have any questions about this notice, or you think that we have not protected your private health information and you wish to complain about it, contact us
Your complaint will be investigated. It is against the law for us to take retaliatory or other negative action against you if you file a complaint.
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