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.
The terms of the Notice of Privacy Practices apply to Mark S. Brigham D.O., Inc., and the licensed professionals and medical staff seeing and treating patients in the office. All of the entities and persons of Mark S. Brigham D.O., Inc., will share the protected 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 patient’s personal health information. We must provide our patients with notice of our legal duties and privacy practice with respect to your protected health information, also known as PHI. We are required to notify you in the unlikely event of a breach or unauthorized disclosure of your personal health information. We are required to abide by the terms of this Notice as long as it remains in effect. We reserve the right to modify the terms of the Notice of Privacy Practices as necessary and to make the new Notice effective for all PHI maintained by us. You may receive a copy of any revised notices at the reception desk at the location listed above, or a copy may be obtained by mailing a request to the Privacy Officer, Mark S. Brigham D.O., Inc., 195 Wadsworth Rd., Suite 401, Wadsworth, OH 44281.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Your authorization (except as outlined below), we will not use or disclose your protected health information (PHI) for any purpose unless you have signed a form or provided an electronic signature authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in support on the authorization. There are certain uses or disclosures of your personal health information for which we will always obtain 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 or as required by law.
- Psychotherapy notes: unless otherwise permitted or required by law.
The following are examples of the types of uses and disclosures of your PHI that the office is permitted to make once you have signed our consent forms, as outlined above. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures.
USES AND DISCLOSURES FOR TREATMENT. We will make uses and disclosures of your protected 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 protected 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 office, you are going to receive other health care, we may release your protected health information to that other health care 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 PHI 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 HEALTH CARE OPERATIONS. We will use and disclose your protected 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 protected health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your protected 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.
FAMILY AND FRIENDS INVOLVED IN YOUR CARE. With your approval, we may, from time to time, disclose your protected 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 protected health Mark S. Brigham D.O., Inc. | 2015 information with such individuals without your approval. We may also disclose limited protected 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 protected 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 contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt-out” of receiving fundraising materials/communications and may do so by sending your name and address to Marketing & Public Relations, Mark S. Brigham D.O., Inc., 195 Wadsworth Rd., Suite 401, Wadsworth, OH 44281 together with a statement that you do not wish to receive fundraising materials or communications from us.
APPOINTMENTS AND SERVICES. We may contact you to provide appointment reminders or test results. You have the right to request, and we will accommodate reasonable requests by you, to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing at the time of registration.
RESEARCH. In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a research organization may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by Mark S. Brigham D.O., Inc., which oversees the research or representation of the researchers that limit their use and disclosure of patient information.
OTHER USES AND DISCLOSURES. We are permitted or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization.
- We may release your protected health information for any purpose required by law;
- We may release your protected health information for public health activities, such as required reporting of disease, injury, birth and death, and for required public health investigations;
- We may release your protected health information as required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
- We may release immunization records to a student’s school but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
- We may release your protected health information to the Food and Drug Administration if necessary, to report adverse events, product defects, or to participate in product recalls;
- We may release your protected health information to your employer when we have provided health care to you at the request of your employer; in most cases, you will receive notice that information is disclosed to your employer;
- We may release your protected health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
- We may release your protected health information if required to do so by a court or administrative ordered subpoena or discovery request; in most cases, you will have notice of such release;
- We may release your protected health information to law enforcement officials as required by law to report wounds and injuries and crimes;
- We may release your protected health information to coroners and/or funeral directors consistent with law;
- We may release your protected health information if necessary, to arrange an organ or tissue donation from you or a transplant for you;
- We may release your personal health information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy;
- We may release your PHI if, in limited instances, we suspect a serious threat to health or safety;
- We may release your protected health information if you are a member of the military as required by armed forces services; we may also release your protected health information if necessary, for national security or intelligence activities; and
- We may release your protected health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.
Ohio law requires that we obtain consent from you in many instances before disclosing the performance or results of an HIV test or diagnosis of AIDS or an AIDS-related condition; before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program; and before disclosing information about mental health services you may have received. For full information on when such consents may be necessary, you can contact Mark S. Brigham D.O., Inc.’s Privacy Officer.
RIGHTS THAT YOU HAVE AND HOW TO EXERCISE THOSE RIGHTS
- ACCESS TO YOUR PROTECTED HEALTH INFORMATION. You have the right to review or receive a copy and/or inspect much of the personal health information we retain on your behalf, unless excluded by law. All requests for access must be made in writing and signed by you or your legal representative. We may charge you a fee for copying the information and for postage, if you request a mailed copy. We will charge for preparing a summary of the requested information if you request a summary. You may obtain an access request from Mark S. Brigham D.O., Inc.
- You have the right to view PHI electronically or receive an electronic copy if the PHI is maintained in electronic format and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and specific with complete name and mailing address of identifying information. We will charge you a fee for our labor and supplies in preparing a copy of the electronic health information.
- AMENDMENTS TO YOUR PROTECTED HEALTH INFORMATION. You have the right to request amendments to the PHI that we retain on you. We are not obligated to all request amendments but will give each request careful consideration. All amendment requests must be in writing and signed by you or your legal representative, and you must state the reason for the request. If an amendment request is honored by us, we may also notify others who work with us and have copies of the uncorrected record if we believe the notification is necessary.
- ACCOUNTING FOR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION. You have the right to receive an accounting of certain disclosures made by us of your PHI. Requests must be in writing and signed by you or your legal representative. The first accounting in a 12-month period is free; you will be charged a reasonable fee as allowed by law for each subsequent accounting you request within the same 12-month period.
- RESTRICTIONS ON USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION. You have the right to request a restriction on the uses and disclosures of your PHI for treatment, payment, and health care operations. 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. We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care service for Mark S. Brigham D.O., Inc., which has been paid in full.
- RIGHT TO CONFIDENTIAL COMMUNICATIONS. You have the right to receive confidential communications of your protected health information by alternative means or at alternative locations. For example, you may request that Mark S. Brigham D.O., Inc., only contact you at work or by mail.
- All requests regarding your protected health information must be made in writing on the appropriate Mark S. Brigham D.O., Inc., request form and submitted to: Privacy Officer, Mark S. Brigham D.O., Inc., 195 Wadsworth Rd., Suite 401, Wadsworth, OH 44281.
- 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 with the Privacy Officer, Mark S. Brigham D.O., Inc., 195 Wadsworth Rd., Suite 401, Wadsworth, OH 44281, in writing, in person, or by calling 330-336-8717. 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.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, Mark S. Brigham D.O., Inc., 195 Wadsworth Rd., Suite 401, Wadsworth, OH 44281.
As a patient, you retain the right to obtain a paper copy of this Notice of Privacy Practices even if you have requested such a copy by email or electronic means
Revised: January 1, 2015