Notice of Privacy Practice
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.
WHO WILL FOLLOW THIS NOTICE:
This notice describes the practices of the Lindner Center of HOPE (LCOH) and each of the health care providers seeing and treating patients at this facility. The information in this Notice of Privacy Practice (Notice) will be followed by:
- Any healthcare professional authorized to enter information into your medical record;
- All departments, programs, and units of LCOH;
- All employees, volunteers, and staff of LCOH;
- Any other entities that have agreed to participate with LCOH as part of an organized health care arrangement for purposes of complying with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations passed thereunder, commonly known as HIPAA. These entities may share personal information with each other for purposes of treatment, payment, and certain health care operations related to the organized health care arrangement
WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION.
We are required by law to maintain the privacy of our patient’s personal health information. We call this information “protected health information” or 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 of Privacy Practices as necessary and to make the new Notice effective for all PHI maintained by us. You may receive a copy of any revised notice by mailing a request to Privacy Officer at Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040. You may view a copy of the notice on our Web site at www.lindnercenterofhope.org.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
LCOH understands that information about you and your health is personal. LCOH is committed to protecting your PHI. LCOH will create a record of the care and services you receive from us. This record is necessary in order to provide you with quality care and to comply with legal requirements. This Notice applies to all of the records of your care generated by LCOH or on LCOH premises. This Notice will tell you about the ways in which LCOH may use and disclose your PHI. This Notice also describes your rights and certain obligations of LCOH regarding the use and disclosure of your PHI.
LCOH is required by HIPAA to:
- maintain the privacy of your PHI in compliance with legal requirements;
- give you this Notice of our legal duties and privacy practices with respect to your PHI; and
- follow the terms of this Notice that are currently in effect.
Generally, we may not use or disclose your PHI, without your permission, except as otherwise permitted under HIPAA or other applicable law. Furthermore, once your permission has been obtained, LCOH must use or disclose your PHI in accordance with the specific terms of your permission. The following are the circumstances under which we are permitted by law to use or disclose your PHI.
USES OR DISCLOSURE OF YOUR PHI WITHOUT YOUR AUTHORIZATION.
Without your authorization or permission, HIPAA allows LCOH to use or disclose PHI in order to provide you with services, and to conduct other related health care operations otherwise permitted or required by law. Also, we are permitted to disclose PHI within and among our workforce and other entities that have agreed to be bound by these policies in order to accomplish these same purposes. However, even with your authorization, we are still required to limit such uses and disclosures to the minimal amount of PHI that is reasonably required to provide those services or complete those activities.
The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosure, this Notice will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all the ways in which we are permitted to use and disclose information without your authorization should fall within one of the categories.
- For Treatment. We will make uses and disclosures of your PHI as necessary for your treatment. For example, doctors, nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, tests, etc. We may also release your PHI to another health care facility or professional who is not affiliated with our organization but who is or will be providing treatment to you. For example, if, after you leave the LCOH, you are going to receive home health care, we may release your PHI to that home health care agency so that a plan of care can be prepared for you.
- For Payment. We will make uses and disclosures of your PHI as necessary for payment purposes. For example, we may forward information regarding your treatment to your insurance company to arrange payment for the services provided to you or we use your information to prepare a bill to send to you or to the person responsible for your payment. We may make uses and disclosure of your PHI to another entity or health care provider for payment for services of the entity that receives the information. For example, we may forward information to the ambulance company that brought you to the LCOH so they can prepare a bill for you or your insurance company for the ambulance service.• For 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, etc. For example, we may use and disclose your PHI for purposes of improving the clinical treatment and care of our patients. We may also disclose your personal health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.
- Our Facility Directory. For inpatient, we maintain a facility directory that lists the name and room number of each patient admitted to an inpatient service. Unless you ask not to be included in the facility directory, or otherwise restrict who you authorize us to disclose this information to, we will disclose to visitors or callers who ask for you by name, and who have been given a 4-digit password that you assign, your name and room number. Other than in an emergency situation or where required by law, we will not disclose your identity without obtaining your or your legal representative’s prior authorization. There is no facility directory used in the outpatient practice.
- Individuals Involved in Your Care or Payment for Your Care. We may disclose your PHI, with your approval, to designated family members, friends, or personal representative who is involved in your care or who helps pay 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 PHI to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
- Fundraising Activities. In preparing fundraising materials and mailing lists, LCOH and/or LCOH business associates are permitted to use your demographic information if you are a current or former patient including your name, address and other contact information, age, gender and insurance status. LCOH is not permitted to use or disclose any PHI about your illness or treatment. You have the right to request that we not send you any future fundraising materials and we will use our best efforts to honor such request. You may make the request by sending your name and address to the Privacy Officer at Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040 or call 513-536-4673, together with a statement that you do not wish to receive fundraising materials or communications from us.
- To Send You Treatment Reminders and Information About Treatment Alternatives or Health-Related Benefits and Services. We may contact you to provide appointment reminders, tests results, 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 example, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to Privacy Officer at Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040.
- Research. Under certain circumstances, we may use or disclose your PHI for research purposes. For example, a research project my involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with patient’s need for privacy of their PHI. Before we use or disclose PHI for research, the project will have been approved through a research approval process. We may, however, disclose your PHI to people preparing to conduct a research project (for example, to help them look for patients with specific medical needs) so long as the PHI they review is not removed from our premises. We may also disclose the PHI of decedents for a research project as long as the PHI is necessary for the research.
- Public Health Activities. We may also disclose information about you to public health authorities for public health activities, such as:
- to prevent or control disease, injury or disability;
- to report births or deaths;
- to report child abuse or neglect;
- to collect or report reactions to medications, food supplements or dietary supplements;
- to collect or report product problems or defects;
- to notify persons of recalls, replacements or repairs relating to products they may be using; and
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease condition.
- Disclosures About Victims of Abuse, Neglect or Domestic Violence. We may disclose PHI to notify the appropriate government authority as required or expressly authorized by law or when the patient agrees if we believe a patient has been the victim of abuse, neglect or domestic violence.
- Health Oversight Committee. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure or disciplinary actions. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
- As Required By Law. We will disclose PHI when required to do so by federal, state or local law.
- To Advert a Serious Threat to Health and Safety. Consistent with Ohio law, we may use and disclose certain PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. In addition, we may use and disclose PHI if we believe that the use or disclosure is necessary for law enforcement to identify or apprehend an individual who has escaped from a correctional institution or from custody.
- Organ and Tissue Donation. We may use or disclose information to an organ procurement or transplant organization or other similar entity for facilitating donation and transplantation.
- Workers’ Compensation. We may release PHI as authorized by (or necessary to comply with) workers’ compensation laws. For example, we may release information to a party responsible for payment of workers’ compensation benefits and to an agency responsible for administering and/or adjudicating claims for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Law Enforcement or Judicial or Government Proceedings. We may disclose your PHI for law enforcement purposes or for judicial or governmental proceedings if required to do so by court order, subpoena or discovery request.
- Coroners/Medical Examiners/Funeral Directors. We may, consistent with applicable law, release PHI to a coroner or medical examiner, or funeral director.
- For Specific Government Functions. We may release PHI of military personnel (and foreign military personnel) in certain situations, and we may release PHI of inmates to correctional facilities in certain situations. We may also release PHI for national security reasons, such as the protection of the President of the United States or for national security duties.
Confidentiality of Alcohol and Drug Abuse Patient Records. The confidentiality of alcohol and drug abuse patient records maintained by the LCOH is protected by federal law and regulations. Generally, we may not say to a person outside the program that you attend a drug or alcohol program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you consent in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law and regulations do not protect any information about a crime committed by you either at our facility or against any person who works for the facility or about any threat to commit such 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.
Ohio law requires that we obtain a consent from you in many instances before disclosing the performance or results of an HIV test or diagnoses of 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. For full information on when such consents may be necessary, you can contact Privacy Officer at Lindner Center of HOPE, 4075 Old Western Row Road, Mason, OH 45040.
OHIO LAW MAY BE MORE STRINGENT THAN HIPAA
Certain provisions of Ohio law may be more stringent than HIPAA. If such provisions are more stringent than HIPAA, then according to HIPAA, we must comply with the more stringent provisions of Ohio law.
OTHER USES OF PROTECTED HEALTH INFORMATION REQUIRE AUTHORIZATION
Other uses and disclosures of PHI not covered by this notice or the laws that apply to LCOH will be made only with your written authorization. Your written authorization is required for uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI. If you give us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time unless we have already taken action in reliance on the authorization. If you revoke your authorization, we will no longer use or disclose PHI for the reason covered by your written authorization, unless you authorized disclosure for a research project and your information is needed to protect the integrity of the project.
You understand that LCOH is unable to take back any disclosures which we have already made with your authorization, and that we are required to retain all records of the care which we provide to you. Any notices that you are revoking your authorization to use your PHI must be in writing and delivered by U.S. mail, in person, or by other reasonable means to the Privacy Officer.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION
You have the following rights regarding PHI which we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and obtain a copy of PHI contained in your designated record set for as long as we maintain the “designated record set.” A “designated record set” contains medical and billing records and any other records that we use for making decisions about your care and treatment. You have the right to view PHI electronically or receive an electronic copy if the PHI is maintained in electronic format. Usually, you have the right to access medical and billing records, subject to certain limitations. For example, you do not have the right to obtain psychotherapy notes or other information if disclosure would have an adverse effect on you or if the information is compiled by us in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.
To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. If you request a copy of the information, we may charge a reasonable, cost-based fee, including postage, to cover the costs associated with your request.
We may deny your request in very limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by LCOH will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Amend. If you feel that PHI in the designated record set which we maintained is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by LCOH.
To request an amendment, you must make the request in writing signed by you or your representative and submit it to the Privacy Officer. In addition, you must provide a reason that supports your request. LCOH may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by LCOH, unless you provide us with reasonable information that the person or entity that created the information is no longer available to make the amendment; is not part of the PHI kept by or for LCOH;
- is not part of the information which you would be permitted to inspect and copy; or
- is accurate and complete.
- Right to an Accounting of Certain Disclosures. You have the right to request an accounting of certain disclosures which LCOH made of your PHI within the six years prior to your request and on or after August 18, 2008. This applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures we may have made to you, with your authorization, in response to a facility directory inquiry, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations.
To request this list or an accounting of the disclosures of your PHI, you must submit your request in writing to the Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before August 18, 2008. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you a reasonable, cost-based fee for the cost of providing the list. LCOH will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any cost is incurred.
- Right to Request Restrictions. You have the right to request a restriction or limitation on our uses and disclosures of your PHI. LCOH uses or discloses PHI for treatment, payment or health care operations. You also have the right to request a limit on the PHI that we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and 2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Privacy Officer. In your request, you must tell the Privacy Officer: (1) what information you want to limit; (2) whether you want to limit LCOH’s use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosure to your spouse or your former clergy. 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 the Privacy Officer.
- Right to Request Change in Communications. You have the right to request that we communicate with you about your PHI n a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request a change in the manner or method of how we communicate with you about your PHI, you must make your request in writing to the Privacy Officer. LCOH will not ask you the reason for your request. LCOH will use reasonable efforts to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a notice in the Event of Breach. We are required to notify you by first class mail or email (if you have told us you prefer toreceive information by e-mail),of any unauthorized acquisition, access, use or disclosure of certain categories of health information if we determine that the breach could pose a significant risk of financial or reputational harm to you.
- Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice. You may ask LCOH to give you a copy of this Notice at any time.
You have the right to receive a paper copy of this Notice. You may ask LCOH to give you a copy of this Notice at any time.
You may obtain a copy of this Notice at www.lindnercenterofhope.org.
To obtain a paper copy of this Notice, please contact the Privacy Officer.
CHANGES TO THIS NOTICE
LCOH reserves the right to change this Notice. LCOH reserves the right to make the revised or changed Notice effective for all PHI which we already have about you as well as any information we receive or create in the future. The Notice will prominently display its effective date. LCOH will post a copy of its current Notice on location and at www.lindnercenterofhope.org.
If you believe your privacy rights have been violated, you may file a complaint with the LCOH Privacy Officer, 4075 Old Western Row Road; Mason, OH 45040. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. All complaints must be submitted in writing.
You will not be penalized by LCOH on the grounds that a complaint was filed.
This Notice of Privacy Practice is effective August 18, 2008.
Revised September 18, 2013.