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Effective September 2018
Notice of Privacy Practices
This Notice of Privacy Practices is provided to you as a requirement of the Health Information Portability
and Accountability Act (HIPAA). Please review it carefully.
If you have any questions about this notice or would like to file a privacy-related complaint, please contact our Privacy Officer: Fisher-Titus Privacy Officer, Corporate Compliance, Fisher-Titus Health, 272 Benedict Avenue, Norwalk, OH, 44857. Phone:
419-668-8101 Ext 6580. E-Mail: email@example.com.
This Notice of Privacy Practices applies to Fisher-Titus Health operating as a clinically integrated health care arrangement composed of: Fisher-Titus Medical Center, Fisher-Titus Home Health Services, Fisher-Titus Foundation, Fisher-Titus Medical Care,
Kaiser Community Pharmacy, and Fisher-Titus Affiliated Services (NCEMS, Mobile Diagnostics). All entities and persons listed will share personal medical information of our patients as necessary to carry out treatment, payment,
and health care operations as permitted by law. Each time you receive services from any of the entities of Fisher-Titus Health, we make a record of the information gathered during your visit. This information is used for
a number of purposes. This document is not all inclusive of those uses. A copy of this notice is listed on www.fishertitus.org.
USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following categories describe different ways we use and disclose medical information without your written
permission. A “use” of your medical information means sharing, accessing, or analyzing medical information within
the Fisher-Titus Health system
. A “disclosure” of your medical information means sharing, releasing, or giving access
to your medical information to a person or company outside of Fisher-Titus Health. Not every use or disclosure in a category will be listed. However, all of the ways that we are allowed to use or disclose your medical information
should fall within one of these categories:
We may use and disclose your medical information to provide you medical care. For example, a physician treating you for an injury may ask another physician to coordinate the different things you need, such as x-rays, lab work,
or prescriptions. We may also disclose medical information to non-Fisher-Titus Health health care providers.
We may use and disclose your medical information to bill and be paid for your treatment. For example, we may give your health insurer information about your treatment so your insurer can provide payment for your services. We
may also provide medical information to other health care providers, such as ambulance companies, to assist in their billing efforts
Health Care Operations:
We may use and disclose medical information for health care operations purposes. These are necessary to make sure all of our patients receive quality care and for management purposes and may include disclosures to third parties
such as billing companies or patient satisfaction surveyors who are performing services for us. The entities and individuals covered by this Notice also may share information with each other for their joint health care
operations and are required to protect the privacy and security of your information.
Other Permitted or Required Uses and Disclosures:
We are permitted or required by law to make certain other uses and disclosures of your personal medical information without your consent or authorization. For example, we will release your medical information, if appropriate,
in the following circumstances:
Appointment and medication reminders. You may request to receive these reminders in a certain way (cell phone, email) or certain place (home, office). We will try to honor all reasonable requests.
Patient directory to include your name, location, general condition and religious affiliation. This may be disclosed to clergy. Your name, location and general condition may be disclosed to any person who asks for a patient by name. You may request any
or all of this information not be disclosed by notifying the Patient Registrar at the time you register.
Fundraising. This will provide you information about Fisher-Titus sponsored activities. You may opt-out of future fundraising communications. We will process your request promptly, but may not be able to stop contacts initiated prior to your opt-out request.
Any purpose required by law to include government oversight agency conducting audits, investigations, or civil or criminal proceedings a required by law.
Public health activities, such as required reporting of disease, injury, birth, death, public health investigations, report reactions to medications, problems with products, notify a person whom may have been exposed
to a disease or may be a risk for contracting or spreading a disease, suspected child abuse or neglect, if we believe you to be a victim of abuse, neglect, or domestic violence, or p
reventing or reducing a serious threat to anyone’s
health or safety, as required by law.
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.
Employer when we have provided health care to you at the request of your employer to determine workplace- related illness or injury; in most cases you will receive notice that information is disclosed to your employer.
Required by a subpoena or discovery request; in some cases, you will have notice of such release.
Law enforcement officials as required by law to report wounds, injuries and crimes.
Coroners, medical examiners and/or funeral directors consistent with law.
Organ or tissue donation from you or a transplant for you.
Research purposes approved by an institutional review board with established rules to ensure privacy.
Members of the military as required by armed forces services; we may also release your personal medical information if necessary for national security or intelligence analysis.
Workers’ compensation agencies, if necessary for your workers’ compensation benefit determination and other
similar legally established programs.
Inmate of a correctional facility, for the purpose of the institution being able to provide you with health care; for your health and safety or the health and safety of others, or the safety and security of the correctional institution.
Ohio law requires we obtain consent from you in many instances before disclosing HIV test or diagnoses of AIDS or an AIDS-related condition; mental health services you may have received; and before disclosing certain information to the State Long-Term
Care Ombudsman. For full information on when such consents may be necessary, you may contact the hospital Health Information Management (HIM) Department.
You may cancel authorization at any time by sending a written request to HIM. We are unable to take back any disclosures we have already made with your authorization.
FOR HEALTH INFORMATION EXCHANGES
We will disclose some of your protected health information to one or more approved Health Information Exchanges (HIE) for the purpose of facilitating the provision of health care to you, as permitted by law. An HIE is an electronic network to facilitate
secure transmission of health information between health care providers. Only authorized individuals may access and use your protected health information for the HIE. We may also use the HIE to disclose information for
public health reporting purposes, for example, immunization reporting. The HIE maintains appropriate administrative, physical and technical safeguards to protect the privacy and security of your protected health information.
YOUR INDIVIDUAL RIGHTS
The records we maintain about your health care are the property of Fisher-Titus Health. To protect your privacy, we may check your identity when you have questions about treatment or billing issues. We will also confirm the identity
You or your personal representative have the right to request in writing at any time that we do not disclose any of
your protected health information to the HIE (“opt out”). Send this written request to the
Fisher-Titus Medical Center HIM, 272 Benedict Ave., Norwalk, OH 44857. We must honor any written request to opt out of the HIE. If you decide to opt out, your data remains in the electronic system, but providers will be
blocked from viewing the data. Any restrictions that you place on the disclosure of your protected health information to the HIE may result in a health care provider not having access to information that is necessary
to render appropriate care to you.
and authority of anyone who asks to review, copy or amend medical information or to obtain a list of disclosures of medical information as described below.
You have certain rights regarding your medical information.
These rights include:
Right to Obtain a Paper Copy of This Notice
at any time.
Right to Inspect and Copy
your medical information upon request. We may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. If it is maintained electronically, we will provide you access to the medical
information in an agreed-upon electronic format. To inspect or copy medical information or to request a review of denied access you may contact the hospital Health Information Management (HIM) Department in writing or by
phone at 419/660-2702, your physician office, Home Health department at 419/668-0099, NCEMS at 419/663- 1367, or Kaiser Community Pharmacy at 419/668-1078, wherever your records are located.
We may deny your
request to inspect, copy or send medical information in certain limited circumstances. If you are denied
access to medical information, you may request the denial be reviewed.
Right to Request Amendments
to your medical information believed to be inaccurate for as long as we maintain the information. To request an amendment, please submit your written request, along with a reason that supports it, to our HIM Department. If
we accept your request, we will tell you and will amend your records by supplementing the information. If we deny your request for amendment, you may submit a statement of disagreement to the Privacy Officer. You have the
right to request we send a copy of your amendment request and your statement of disagreement (if any) with any future disclosures of your medical information.
Right to an Account of Disclosures
of your personal medical information for six years prior to the date of your request. The first list you request in a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list.
To request an accounting of disclosures, please submit your request to our HIM department at the address listed at the top of this notice.
Right to Request Restrictions
on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request we disclose a limited amount of medical information to someone involved in your care
or involved in payment for your care. We are not required to agree to your restriction request. If we do agree, we will notify you in writing and will honor our agreement unless we need to use or disclose the information
to provide emergency treatment to you or if the law requires us to disclose it. We will agree to your request to restrict disclosure of your medical information to a health plan if the disclosure is for the purpose of payment
or health care operations; is not otherwise required by law; and the medical information you wish to restrict pertains solely to a health care item or service for which you, or someone other than your health plan, has paid
Right to Request Confidential Communications
regarding health matters in a certain way or at a certain location. For example, you can ask we only contact you at work or by e-mail. We will honor all reasonable requests. However, if we are unable to contact you using your
requested methods or locations, we may contact you using any information we have.
Right to Notice of a Breach of Certain Medical Information
by first class mail or e-mail (if you have told us you prefer to receive information by e-mail), as required. A breach is any unauthorized acquisition, access, use, or disclosure of certain categories of medical information
compromising the security or privacy of this medical information.
Right to Choose Someone to Act for You
if you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your medical information. We will make sure the person has this authority
and can act for you before we take any action.
CHANGES TO THIS NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
You may file a written or verbal complaint with us if you believe your privacy rights have been violated. If you have any privacy-related questions or complaints, please contact our Privacy Officer using one of the methods listed above. 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 or OCRComplaint@hhs.gov. We support your right to privacy of
your medical information and you will not be penalized for filing a complaint.