Privacy Statement

NOTICE OF PRIVACY PRACTICES-SEVEN HILLS MEDICAL ARTS, INC. I. 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 IN DETAIL. The terms of this Notice of Privacy Practices (Notice) applies to Seven Hills Medical Arts, Inc.. We will share protected health information (PHI) of patients as necessary to carry out treatment, payment, and healthcare operations as permitted by law. II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PHI We are required by law to maintain the privacy of our patients’ PHI. We must provide patients with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all PHI maintained by us. You may receive a paper copy of this or any revised Notice. III. USES AND DISCLOSURES OF YOUR PHI Your Authorization We will not use or disclose your PHI for any purpose other than treatment, payment and healthcare operations unless you have signed a form authorizing the use or disclosure with the exception of the situations outlined below. You have the right to revoke said authorization in writing unless we have taken any action in reliance on the authorization. Treatment We will make uses and disclosures of your PHI as necessary for your treatment. For instance, doctors, nurses, medical students, other trainees and employees involved in your care will use information in your medical record and information that you provide about your symptoms to plan a course of treatment for you that may include procedures, medications and tests. Your PHI may be disclosed outside our facility to other physicians or entities that are involved in your care. Payment We will make uses and disclosures of your PHI as necessary for payment purposes. 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. We may make uses and disclosures of your PHI to another entity or health care provider for payment of the entity that receives the information. For instance, we may forward information to the transportation company that brought you to the office so they can prepare a bill for you or your insurance company for the transportation service. Health Care Operations We will use and disclose your PHI as necessary, and as permitted by law, for our health care operations, which include clinical improvement, professional peer review, business management, accreditation, and licensing. We may use and disclose your PHI for quality improvement activities. Family and Friends Involved In Your Care With your approval, we may disclose your PHI to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate your care or payment 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 PHI with such individuals without your approval. We may also disclose limited PHI 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 elements of your PHI to one or more of these outside persons or organizations who assist us with our healthcare operations. In all cases, business associates are required 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 or communications and may do so by calling Dr. Peter Kambelos at (513) 385-2566. You may also mail your name and address to our office at 4767 North Bend Road, Suite A, Cincinnati, OH 45211. Please, include a brief statement outlining your wishes not to receive fundraising materials or communications from us. Marketing We must receive your authorization for any use or disclosure of PHI for marketing, except if the communication is in the form of a face-to-face communication made to you personally; or a promotional gift of nominal value provided by our office. It is not considered marketing to send you information related to your individual treatment, case management, and care coordination or to direct or recommend alternative treatment, therapies, health care providers or settings of care. These may be sent without written permission. If the marketing is to result in direct or indirect payment to our office by a third party we will state this on the authorization. Sale Your PHI will not be sold without your written permission unless a transaction occurs resulting in the sale of the Practice, in which case all patient medical records become the property of the purchasor. Appointments and Services We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You have the right to request to receive communications regarding your PHI from us by alternative means or at alternative locations. We agree to comply with reasonable requests. For instance, if you wish appointment reminders to no to be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You must request such confidential communication in writing and send your request to our office. Confidentiality of Alcohol and Drug Abuse Records Federal law and regulations protect the confidentiality of alcohol and drug program records maintained by this facility. PHI containing detailed information on your alcohol or drug use may not be disclosed without 1) your written authorization; 2) a court order; or 3) unless the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation. Federal law or regulations do not protect any information about a crime committed by you at our facility or about any threat to commit a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. Other Uses and Disclosures We are permitted or required by law to make certain other uses and disclosures of your PHI without your authorization. We may release your PHI for any purpose required by law; if we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence; to law enforcement officials as required by law to report wounds, injuries and crimes; if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings; and if required to do so by a court or administrative order, subpoena, or discovery request; in most cases you will have notice of such release; We may release your PHI for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations; we may release your PHI to coroners and/or funeral directors consistent with law; We may release your PHI to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls; We may release your PHI 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 PHI if necessary to arrange an organ or tissue donation from you or a transplant for you; We may release your PHI if in limited instances we suspect a serious threat to health or safety; We may release your PHI for certain research purposes without your authorization when such research is approved by an institutional review board with established rules to ensure privacy or with researcher representation that limit the use and disclosure of the PHI; We may release your PHI if you are a member of the military as required by armed forces services; We may also release your PHI if necessary for national security or intelligence activities; We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations; and We may release your PHI to workers’ compensation agencies if necessary for your workers’ compensation benefit determination. Ohio law requires that we have your authorization or a court order before disclosing the results of an HIV test or diagnosis of AIDS or AIDS-related condition. IV. RIGHTS THAT YOU HAVE REGARDINGYOUR PHI Access to Your Protected Health Information You have the right to review or receive a copy and/or inspect much of the PHI we retain on your behalf, unless excluded bylaw. All requests for access must be made in writing and signed by you or your legal representative. You have the right to view PHI electronically or receive an electronic copy if the PHI is maintained in electronic format. We may charge you a fee for copying the information and for postage if you request a mailed copy. Amendments to Your Protected Health Information You have the right to request that PHI that we maintain about you be amended. 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 request. If an amendment you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. Accounting for Disclosures of Your PHI You have the right to receive an accounting of certain disclosures made by us of your PHI. Requests must be made in writing and signed by you or your legal representative. The first accounting in any 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 PHI 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. You also have the right to terminate, in writing, any agreed to restriction by sending a termination notice. We will agree to a restriction on the disclosure of your protected health information to a health plan if the disclosure is for the purposes of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service that you and not your health plan have paid us for in full out of pocket. CONTACT INFORMATION Peter J. Kambelos, M.D., F.A.C.P., President and Privacy Officer, Seven Hills Medical Arts, Inc., 4767 North Bend Road, Suite A, Cincinnati, Ohio 45211. Telephone (513) 385-2566. V. HOW TO COMPLAIN ABOUT OURPRIVACY PRACTICES If you believe your privacy rights have been violated, you may file a complaint in writing to the address above. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights, Region V, 233 N. Michigan Avenue, Suite 240, Chicago, IL 60601 in writing within 180 days of an alleged violation of your rights. There will be no retaliation for your filing a complaint. VI. PERSON TO CONTACT FOR FURTHERINFORMATION OR ASSISTANCE If you have questions or need further assistance regarding this Notice, contact Peter J. Kambelos, M.D., F.A.C.P. at the address and telephone number listed above. As a patient you retain the right to obtain a paper copy of this Notice, even if you have requested such copy by email or other electronic means. Edited 9/1/13