JOHN B. DEVINE, M.D. INC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY AND ACKNOWLEDGE RECEIPT BY YOUR SIGNATURE ON THE ACKNOWLEDGEMENT FORM.
If you have any questions about this Notice please contact Janet Antal, LPN - Privacy Officer.
This Notice describes how John B. Devine, M.D. Inc. may use and disclose your protected health information. The terms of this Notice of Privacy Practices are effective April 14, 2003. This office will share patient health information as is necessary to provide quality health care and receive reimbursement for those services as permitted by law. This office is required by law to maintain the privacy of our patients' health information and to provide patients with this Notice of Privacy Practices. This office will abide by the terms of this Notice so long as it remains in effect and we reserve the right to change the terms of this Notice of Privacy Practices as necessary. A copy of any revised notices will be available in this office, or, upon request to Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311, a copy may be mailed to your address maintained on file.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
This office is committed to maintaining the confidentiality of your health information. However, your health information may be used and disclosed as customary and reasonable for purposes of treatment, payment, and health care operations pursuant to a signed consent and authorization form. You have the right to revoke the authorization form in writing and dated. Any prior action that has been taken in reliance on the prior authorization is exempt.
Treatment, Payment, and Health Care Operations. This office will use and disclose your health information for purposes of treatment, payment, and as otherwise necessary and permitted by law, and your signed consent and/or authorization form, for our health care operation. This may include disclosure to another health care provider who, at the request of your physician, becomes involved in your treatment, or for purposes of approval of reimbursement from your
health plan.
Business Associates. At times, it may be necessary for us to provide your health information to certain outside persons or organizations that assist us with our health care operations, such as auditing, accreditation, legal services, etc. These business associates are required to properly safeguard the privacy of your health information.
Family and Friends. With your approval and using our professional judgment, your health information may be disclosed to designated family, friends, and others who are directly involved in your care or in payment of your care. If you are unavailable, incapacitated or in an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited health information with such individuals without your approval.
Appointments and Services. This office 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, and we will accommodate your reasonable requests, to receive communications regarding your health information from us by alternative means or at alternative locations.
You may request such confidential communication in writing and may send your request to Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311.
Other uses and disclosures of your individual health information, permitted or required by law, may be made without your consent or authorization.
- Use or disclosure of your health information for any purpose required by law;
- Use of disclosure of your health information for public health activities, such as required reporting of disease, injury, birth and death, and for required public health investigations;
- Use or disclosure of your health information as required by law if we suspect child abuse or neglect; we may also release your individual health information as required by law if we believe you are a victim of abuse, neglect, or domestic violence;
- Use or disclosure of your health information, if necessary, to the Food and Drug Administration;
- Use or disclosure of your health information to your employer when we have provided health care to you at the request of your employer;
- Use of disclosure of your health information if required by law to a government oversight agency conducting audits, investigations, civil or criminal proceedings;
- Use or disclosure of your health information if required by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release;
- Use or disclosure of your health information to law enforcement officials;
- Use or disclosure of your health information to coroners and/or funeral directors consistent with law;
- Use or disclosure of your health information if necessary to arrange and organ or tissue donation or transplant
- Use or disclosure of your health information if you are a member of the military as required by armed forces services; we may also release your individual health information if necessary for national security or intelligence activities; and
- Use or disclosure of your health information to workers' compensation agencies.
YOUR RIGHTS
- Restrictions on Use and Disclosure of Individual Health Information. You have the right to request restrictions on some of our uses and disclosures of your health information. These restrictions must be made in writing and signed by you or your representative. This office is not required to agree to your restrictions. 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 or orally, any agreed-to restriction by sending such termination notice to Janet Antal, LPN - Privacy Officer, John B. Devine M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311.
- Access to Individual Health Information.. You have the right to inspect and copy your health information maintained by this office. All requests for access must be made in writing and signed by you or your representative. A fee according to Ohio Law will be accessed. There will also be a charge for postage if you request a mailed copy and, if requested, for preparation of a summary of the requested information. You may obtain a request for access form from Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311. In certain circumstances, you may not be permitted access (e.g., psychotherapy notes, information compiled for legal action, or information subject to prohibition by law). Depending on the circumstances, you may request a review of the decision to deny access. Please contact Janet Antal, LPN, Privacy Officer, for questions about access to your health information.
- Amendments to Individual Health Information. You have the right to request in writing that your health information maintained by this office by amended of corrected. In certain cases, we may deny your request for amendment. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the amendment. If we make an amendment, we may also notify others who work with us and have copies of the un-amended record if we believe that such modification is necessary. You may obtain an amendment request from Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311. If we deny your request, you may submit a statement of disagreement to us and we may prepare a rebuttal that will be provided to you. These materials may be distributed in future requests to review your health information. Please contact Janet Antal, LPN - Privacy Officer, for questions about amendments to your health information.
- Accounting Disclosures of Individual Health Information. You have the right to receive an accounting of certain disclosures made by us of your health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. Accounting request forms are available from Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311. The first accounting in any 12-month period is free; you will be charged a fee of $20.00 for each subsequent accounting you request within the same twelve-month period. The right to receive this information is subject to certain exceptions, restrictions, and limitations.
COMPLAINTS
If you believe your privacy rights have been violated you may file a written complaint with Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. Filing a complaint will not cause retaliation or us to treat you badly.
ADDITIONAL INFORMATION
If you have questions or need additional assistance regarding this Notice, you may contact Janet Antal, LPN - Privacy Officer, John B. Devine, M.D. Inc. 676 South Broadway Street, Suite 102 Akron, Ohio 44311, telephone (330) 344-4017.