Important

This notice describes how information about you may be disclosed, and how you can access this information.

Please review it carefully

Disclosure Without Your Consent

We are permitted or required by law to make certain other uses and disclosures of your PHI without your consent or authorization. We may release your PHI :

• For any purpose required by law;

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

• As required by law for suspect child abuse, neglect, abuse, or domestic violence;

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

• To your employer when questions arise about workplace related illness or injury. In most cases you will receive notice this information was disclosed to your employer;

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

• If required to do so by subpoena or discovery request;

• To law enforcement to report wounds, injuries and crimes;

• In serious instances if we suspect a serious treat to health or public safety;

• If you are a member of the military as required by the Armed forces Services; we may also release your PHI if necessary for national security or intelligence activities;

• To workers’ compensation agencies if necessary for your workers’ compensations benefit determination.

Your Rights

This Notice is about your rights concerning personal and medical information. In order to provide you with quality care, we create a record of care and services provided to you by our office. The privacy of this record is very important to us. It is our legal duty to comply with the standards set forth by The Health Insurance Portability Accountability Act of 1996 which requires us to keep your PHI (protected health information) private.

You have the following rights with respect to your personal information, which you may exercise by presenting our office with a written request:

• The right to request restrictions on certain uses and disclosures of your PHI, including those related to disclosures to family members, other relatives, close personal friends, or any other person (s) identified by you. We are not however, required to agree to a requested restriction. If we agree to a restriction, we must abide by it unless you agree in writing to remove it.

We may use and disclose your PHI only for treatment, payment, and health care operations.

For Treatment, we may use your PHI to provide you with medical treatment or services. This means we may disclose medical information about you to doctors, technicians or other health care providers who are treating you.

For Payment we may disclose your medical information for reimbursement for services, to confirm coverage, and for billing and collections.

For Healthcare Operations we may use and disclose your PHI for our healthcare operations. This may include conducting programs for training, employee evaluations, auditing, or measuring and improving quality and getting licenses, certificates and credentials we need to serve you.

According to HIPAA privacy rules, you have the right to keep all information regarding your visits to this office confidential. Occasionally this office will send greeting cards, sympathy cards, postcards, or call you regarding an appointment. Please provide our office with a written notice if you disagree with the use of any of your personal information for these purposes

Complaints

If you believe your rights have been violated you may file a complaint. There will be no retaliation for filing such a complaint.

Complaints may be addressed to:

Southern Ohio Foot and Ankle Associates
1130 Western Avenue
Chillicothe, OH 45601

Or,

Office of Civil Rights
U.S. Department of Health and Human Services
233. N. Michigan Avenue
Chicago, IL 60601