Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information.

Why you are receiving this information:

The federal government requires all health care providers to make this information about the privacy of your medical records available to you.  The government also requires us to give you the opportunity to respond with a written acknowledgement that you have received the information.  A link to an on-line acknowledgement form is provided for that purpose.

Please follow these steps:

1. Review this information carefully.


2. After reading, click on the link to the acknowledgement form, and, if you wish to do so, complete the form and submit it on-line.  Remember that we are required by law to give you the opportunity to complete the acknowledgement form, but you are not required by law to do so.

Text of the Notice of Privacy Practices

1. Purpose:  The Clinic and its professional staff, employees, and volunteers and all of its affiliated entities including the Fauster-Cameron, Inc (referred to collectively as Clinic) follow the privacy practices described in this Notice.  The Clinic maintains your personal health information in records that will be maintained in a confidential manner, as required by law.  This health information may include photographs obtained by authorized personnel at THE CLINIC for treatment purposes.  THE CLINIC must use and disclose your health information to the extent necessary to provide you with quality health care.  To do this, THE CLINIC must share your health information as necessary for treatment, payment and health care operations.


2. What Are Treatment, Payment, and Health Care Operations?  Treatment includes sharing information among health care providers involved in your care.  For example, your physician may share information about your condition with the pharmacist to discuss appropriate medications, or with radiologist or other consultants in order to make a diagnosis.  THE CLINIC may use your health information as required by your insurer or HMO to obtain payment for your treatment and hospital stay.  We also may use and disclose your health information to improve the quality of care, e.g., for review and training purposes.


3. How Will the Clinic Use My Health Information?  Your health information may be used for the purposes listed below, unless you ask for restrictions on a specific use or disclosure:

   Ø      Family members or close friends involved in your care or payment for your treatment.

   Ø      Disaster relief agency if you are involved in a disaster relief effort.

   Ø      Appointment reminders

   Ø      To inform you of treatment alternatives or benefits or services related to your health.  (You will have an opportunity to refuse to receive this information.)

   Ø      As required by law.

   Ø      Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting child abuse or neglect; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect or domestic violence (if you agree or as required by law).

   Ø      Health oversight activities, e.g., audits, inspections, investigations, and licensure.

   Ø      Lawsuits and disputes.  (We will attempt to provide you advance notice of a subpoena before disclosing the information.)

   Ø      Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an individual being sought by authorities; about the victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred on Clinic’s premises; and in emergency circumstances relating to reporting information about a crime.)

   Ø      Coroners, medical examiners, and funeral directors.

   Ø      Organ and tissue donation.

   Ø      Certain research projects.

   Ø      To prevent a serious threat to health or safety.

   Ø      To military command authorities if you are a member of the armed forces or a member of a foreign military authority.

   Ø      National security and intelligence activities.

   Ø      Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.

   Ø      Inmates.  (Medical information about inmates of correctional institutions may be released to the institution.)

   Ø      Workers’ Compensation.  (Your health information regarding benefit for work-related illnesses may be released as appropriate.)

   Ø      To carry out health care treatment, payment, and operations functions through business associates, e.g., to install a new computer system.

   Ø      As a pharmacy, we may use and disclose your PHI as necessary to maintain a patient profile, which may include information about you; your medical condition, medications, and prescription devices that you use; any allergies that you may have; and other information, such as health insurance that you may have.

   Ø      As a pharmacy, we may use and disclose you PHI in dispensing prescription medicines and related products and services, including counseling you and your caregivers about proper use of your medications.

   Ø      We may discuss such problems with your other health care professionals, such as your physician or dentist, and through discussions we may use and disclose your PHI.

   Ø      We may use or disclose your PHI to you and your caregivers in our discussions with you and your caregivers about your treatment.

   Ø      Activities related to billing may include claims management, collections, and related health care data processing.

   Ø      Depending on who pays for the health care products and services that we provide you, other activities may include may include determination of eligibility or coverage; medical necessity; review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; utilization review activities, including pre-certification and preauthorization of services; concurrent and retrospective review of services; and disclosure to consumer reporting agencies of some or all of the following PHI necessary for collection of payment:  name and address; date of birth; social security number; payment history; account number or numbers; and name and address of the health care provider and/or health plan.



4. Your Authorization Is Required for Other Disclosures.  Except as described above, we will not use or disclose your health information unless you authorize (permit) the Clinic in writing to disclose your information.  You may revoke your permission, which will be effective only after the date of your written revocation.


5. You Have Rights Regarding Your Medical Information.  You have the following rights regarding your health information, provided that you make a written request to invoke the right on the form provided by the Clinic: 

   Ø      Right to request restriction. You may request limitations on your health information we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular surgery), but we are not required to agree to your request.  If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

   Ø      Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted.

   Ø      Right to inspect and copy. You have the right to inspect and copy your health information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. We may charge a fee for copying, mailing and supplies.  Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by the Clinic.  The Clinic will comply with the outcome of the review.

   Ø      Right to request amendment. If you believe that the health information we have about you is incorrect or incomplete, you may request an amendment on the form provided by the Clinic, which requires certain specific information.  The Clinic is not required to accept the amendment.

   Ø      Right to accounting of disclosures. You may request a list of the disclosures of your health information that have been made to persons or entities other than for health care treatment payment or operations in the past six (6) years, but not prior to April 14, 2003.  After the first request, there may be a charge.

   Ø      Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy.

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6. Requirements Regarding This Notice.  The Clinic is required by law to provide you with this Notice.  We will be governed by this Notice for as long as it is in effect.  The Clinic may change this Notice and these changes will be effective for health information we have about you as well as any information we receive in the future.  Each time you register at the Clinic for health care services as an inpatient or outpatient, you may receive a copy of the Notice in effect at the time.


7. Complaints.  If you believe your privacy rights have been violated, you may file a complaint with the Clinic or with the Secretary of the Unites Stated Department of Health and Human Services.  You will not be penalized or retaliated against in any way for making a complaint to the Clinic or the Department of Health and Human Services.

THE CLINIC Contact:

You may call the Clinic Privacy Officer at 419.783.3318 if:

• You have a complaint
• You have any questions about this Notice
• You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or You wish to obtain a form to exercise your individual rights described in Paragraph 5.

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After you have finished reading this information carefully, click here to complete the voluntary acknowledgement form.