BOWLING GREEN CLINIC, INC.

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE, WHICH IS EFFECTIVE APRIL 1, 2003, DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

Each time you visit Bowling Green Clinic, Inc., we make a record of the information gathered during your visit. This information is used for a number of purposes. These uses are set forth below. You have certain rights regarding this information. Your rights regarding this information are set forth below. Finally, we have certain responsibilities regarding our use of your information. Our responsibilities are set forth below.

 

USES AND DISCLOSURES OF HEALTH INFORMATION

 

We are permitted by law to use your health information to provide treatment to you. For example, we will provide the physician and our other clinicians involved in your care and treatment with the information in our records to assist the physician in providing proper care to you. We will also provide this information to subsequent health care providers. There individuals may create additional information related to the care and treatment they provide you.

 

We are permitted by law to use your health information to obtain payment for our services. For example, we may send your insurance company or other payor a bill that may include your health information.

 

We are permitted by law to use your health information to perform our regular health care operations. For example, we may use your health information to assess the quality of care we provide in order to maintain our standards.

 

 

We are permitted, and in some cases required, by law to make certain other disclosures of health information without your consent. We may disclose your health information, if appropriate, to the following entities under the following circumstances:

 

1.      to public health agencies to satisfy certain reporting requirements, such   as births and deaths, certain communicable diseases, child abuse, and other public health issues;

2.      to health oversight agencies, such as governmental auditors, the Ohio Department of Health, and other agencies when required;

3.      to any individual when ordered by a court or other legal process to do so;

4.      to law enforcement officials when necessary for law enforcement purposes and required by law;

5.      to a coroner or medical examiner when necessary to enable them to perform their duties;

6.      to organ procurement organizations, to enable them to make suitability    determinations;

7.      in cases of emergency;

8.      to researchers if their research has been approved by an institutional review board and they take certain steps to protect your privacy;

9.      to avert serious threats to health or safety;

10.     specialized government functions regarding military personnel and military veterans, certain national security purposes, and inmates;

11.     Workers compensation to the extent necessary to comply with applicable laws.

 

ANY USES OR DISCLOSURES OTHER THAN THOSE LISTED ABOVE REQUIRE US TO OBTAIN YOUR WRITTEN AUTHORIZATION, WHICH YOU MAY REVOKE AT ANY TIME. ANY SUCH REVOCATION MUST BE IN WRITING.

 

 

 

YOUR INDIVIDUAL RIGHTS

 

1.      You have certain rights regarding your health information. These rights include:

2.      the right to obtain a paper copy of this notice;

3.      the right to inspect and copy your health information (copies are available for a reasonable fee)

4.      the right to request amendments to your health information you believe        to be inaccurate;

5.      the right to obtain an accounting of our uses and disclosures of your information (although we are not legally obligated to honor this request);

6.      the right to request that communications regarding your health information be sent by alternative means or at alternative locations.

 

OUR RESPONSIBILITES

 

We are required by law to maintain the privacy of your information in accordance with this notice. We are also required to provide you with this notice explaining our duties and practices regarging your health information. We are required to abide by the terms of this notice.

 

We reserve the right to change the content of this notice and to make new provisions regarding your protected health information. We will provide you a revised notice during your first visit after the revisions are effective.

 

COMPLAINTS

 

If you believe we have violated your privacy right, you may file a written complaint to our Privacy Officer and/or to the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

 

If you want more information or you believe your rights have been violated, you may contact our Privacy Officer at the following address: Bowling Green Clinic, Inc.. 1039 Haskins Rd., Bowling Green OH 43402. Our telephone number is 419-352-1121. Alternatively, you may wish to contact the federal agency in charge of enforcing patient’s privacy rights. That address is: Office for Civil Rights, U.S. Dept. of Health and Human Services, 200 Independence Ave. S.W., Room 509F, HHS Building, Washington D.C.