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.
This Notice describes the privacy practices of Memorial Hospital and the physicians who provide services to patients at this hospital.
Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information.
How We Use Your Patient Health Information
We use health information about you for treatment, to obtain payment, and for health care operations, including administrative purposes and evaluation of the quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your consent.
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 the 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 the directory.
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 the Foundation Development Director together with a statement that you do not wish to receive fundraising materials or communication from us.
Examples of Treatment, Payment, and Health Care Operations
Treatment:We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care or paying for your care.
We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan.
Health Care Operations:
We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, professional peer review, business management, accreditation and licensing, and to assess the care and outcomes of your case and others like it.
We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Other Uses and Disclosures
We may use or disclose identifiable health information about you for other reasons, even without your permission. Subject to certain requirements, we are permitted to give out health information without your permission for the following purposes:
- Required by Law: We may be required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.
- Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.
- Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility of government programs, and similar activities.
- Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena or court order.
- Law Enforcement Purposes: Subject to certain restrictions, we may disclose information required by law enforcement officials.
- Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.
- Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.
- Research: We may use or disclose information for approved medical research.
- Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness. We may release your personal 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.
- Abuse & Neglect: We may release your personal health information as required by law if we suspect child abuse or neglect or if we believe you to be a victim of abuse, neglect, or domestic violence.
Ohio law requires that we obtain consent from you in many instances: before disclosing the performance or results of any 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.
We may also ask if we can disclose limited information about you to clergy or include it in the Hospital directory. Under limited circumstances, we may disclose information to notify or locate your relatives or to assist disaster relief agencies.
In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.
You have the following rights with regard to your health information. Please contact the person listed below to obtain the appropriate forms for exercising these rights.
You may request restrictions on certain uses and disclosures of your health information. Requests must be made in writing by you or your representative. We are not required to agree to such restrictions, but if we do agree, we must abide by those restrictions.
You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.
Inspect and Obtain Copies:
In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for the copies.
If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct the existing information or add the missing information. We are not obligated to make all requested amendments, but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction requested.
Accounting of Disclosures:
You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or health care operations. Requests must be made in writing and signed by you or your representative. There is no cost for this accounting. Accounting request forms are available from Health Information Services.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect.
Changes in Privacy Practices
We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the admissions area. You can also request a copy of our Notice at any time. For more information about our privacy practices, contact the person listed below
If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services in Washington D.C. within 180 days of a violation of your rights. The person listed below will provide you with the appropriate address upon request. You will not be penalized in any way 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.
If you have any questions, requests, or complaints, please contact:
Chief Patient Services Officer
715 South Taft Avenue
Fremont, Ohio 43420
Memorial Hospital and the physicians who practice at the hospital are independent contractors and do not hereby assume any liability for the services or conduct of each other.
The effective date of this Notice is April 14, 2003.