NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES

Dear Patient:

Welcome to Marysville Primary Care, Inc. We wanted you to know that we are required by federal law to give you the following document. It is called a Notice of Privacy Practices. We are also required to have you sign a written acknowledgment form that you have received this document. This document describes how we use and disclose medical information and how you can get access to this information. Please read it carefully.

Thank you again for being our patient. Please do not hesitate to contact us if you have any questions.

Marysville Primary Care, Inc.

David Applegate II, M.D.
Mary Applegate, M.D.
Beth Brake
Marissa Forrest, C.N.P.
Peter Mustillo, M.D.
Julie Sabo, C.N.P.

NOTICE OF PRIVACY PRACTICES (NPP)

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?

The terms of this Notice of Privacy Practices apply to Marysville Primary Care, Inc., operating as a clinically integrated health care arrangement composed of the physicians, nurse practitioners, and other licensed professionals seeing and treating patients in this practice. The members of this clinically integrated health care arrangement work and practice at 1044 Columbus Avenue, Marysville, Ohio 43040. All of the entities and persons listed will share health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all your records of your care generated by us at the office, whether made by our office staff personnel or our physicians.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all protected health information maintained by us. You may pick up a copy of the revised notice at our office anytime during regular business hours.

We are required by law to:

make sure that medical information that identifies you is kept private;

give you this notice of our legal duties and privacy practices with respect to medical information about you, and;

follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

Authorization We will not use or disclose your health information for any purpose unless you have signed a form authorizing the use or disclosure except as outlined below or as otherwise permitted by law. You have the right to revoke that consent or authorization in writing unless we have taken any action in reliance on the consent or authorization.

Treatment We will make uses and disclosures of your health information as necessary for your treatment. 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 health information to another health care facility or professional who is not affiliated with our practice but who is or will be providing treatment to you. For example, if after you leave the office, you are going to receive hospital care, we may release your health information to that hospital so that a plan of care can be prepared for you.

Payment We will make uses and disclosures of your health information as necessary for payment purposes of those health professionals and facilities that have treated you or provided services to you. 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.

Health Care Operations We will use and disclose your health information as necessary, and as permitted by law, for our health care operations which include quality improvement, professional peer review, business management, etc. For example, we may use and disclose your health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your health information to another health care facility, health care professional, or health plan for such things as quality improvement and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.

Family and Friends Involved in Your Care or Payment for Your Care We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so your family can be notified about your condition, status and location. Information will also be provided if a friend or family member calls in and wants to know if you have left the office or not.

Appointment Reminders We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office. This includes written appointment reminders and telephone, fax, or E-mail reminders. We will accommodate reasonable requests by you to receive communications regarding your health information from us by alternative means or at alternative locations. We will accommodate reasonable requests. For example, you wish appointment reminders to not be left on voice mail or sent to a particular address. We have a special form to fill out, which can be obtained at our office during regular business hours.

Phone Contacts We may also contact you by phone to provide you with test results, return your call, answer questions, obtain additional information on billing, or other related issues. If you are not in, we will leave information such as our name, the name of our office, the person we are calling, our phone number, and the date and time of your appointment.

To Avert a Serious Threat to Health or Safety We may use and disclose medical information 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. Any disclosure would only be to someone able to help prevent the threat.

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 health information 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. Business Associates are also required by law to protect your confidentiality and privacy and they sign a contract to this effect.

Health Products and Services We may from time to time use your health information to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.

Research In limited circumstances, we may use and disclose your health information for research purposes. For example, a researcher may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board, which oversees the research, or by representations of the researchers that limit their use and disclosure of patient information.

Other Uses and Disclosures We are permitted or required by law to make certain other uses and disclosures of your health information without your consent or authorization. We can release your health information for the following reasons:

For any purpose required by law;

For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;

As required by law if we suspect child or elder abuse or neglect. We may also release your health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;

To the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;

To report problems with medications or products;

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;

If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;

If required to do so by a court or administrative ordered subpoena or discovery request; in most cases you will have notice of such release;

To law enforcement officials as required by law to report wounds and injuries and crimes;

To coroners and/or funeral directors consistent with law;

For certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy;

In limited instances if we suspect a serious threat to health or safety, but only to someone who would be able to help prevent the threat,

If you are a member of the military as required by armed forces services; we may also release your health information if necessary for national security or intelligence activities;

To worker’s compensation agencies, if necessary, for your worker’s compensation benefit determination.

To the Victims of Crime Division, at the State Attorney General’s Office, to help you get financial assistance if you have been the victim of a crime or sexual assault, but only if you authorize this;

To report gunshot wounds, knife stabbings, suspicious injuries, and burn, as required by Ohio law;

To report a death, if we believe it to be caused by criminal conduct;

To a coroner or medical examiner, as allowed by law, to identify a deceased patient or to determine the cause of death;

To a funeral director, as necessary to carry out their duties.

SPECIAL CIRCUMSTANCES

Health Oversight Activities We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement We may release medical information if asked to do so by a law enforcement official.

Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

HIV or drug and alcohol treatment 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 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.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. This usually includes medical billing and records.

To inspect and copy medical information 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 fee for the costs of copying, mailing or other supplies associated with your request. This fee is set by Ohio law.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by our office 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 medical information we have about you 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 our facility.

To request an amendment, your request must be made in writing and submitted to our offices on our designated forms. In addition, you must provide a reason that supports your request.

We 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 us, unless the person or entity that created the information is no longer available to make the amendment;

Is not part of the medical information kept by or for the office;

Is not part of the information which you would be permitted to inspect and copy or;

Is accurate and comple

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures". This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to our office during regular business hours. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. 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 on our designated forms. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Rights to Reasonable Accommodations: You have the right to request that we communicate with you about medical matters in 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 confidential communications, you must make your request in writing to the office privacy officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the privacy officer at our office.

CONTACTS

Contact the Privacy Officer at (937) 644-1441 if you have any questions about the notice or for further information.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with the office, contact the Privacy Officer at 937-644-1441. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

04/2003