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 Authorized HIPAA Representative Release Form

 

As a Patient and Visitor of Blanchard Valley Health System:

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 IT CAREFULLY.

Terms of the Notice of Privacy Practice

This Notice of Privacy Practice (Notice) is provided to you as a requirement of the Health Information Portability and Accountability Act (HIPAA). The terms of this Notice of Privacy Practices apply to Blanchard Valley Health System (BVHS) operating as a clinically integrated health care arrangement composed of Blanchard Valley Regional Health Center, Continuing Care Services and Blanchard Valley Medical Practices. The members of this clinically integrated health care arrangement work and practice at Blanchard Valley Hospital, Bluffton Hospital, Birchaven Village, Independence House, Bridge Home Health & Hospice, Physicians Plus Urgent Care, Primary Care Medical Offices, BVHS Specialty Physician Offices, Caughman Health Center, Julie Cole Rehabilitation & Sports Medicine, Women & Children’s Center, Well at Work Occupational Health, Creighton Dialysis, Armes Family Cancer Care Center, EasternWoods Outpatient Center, Sak Sleep Wellness Center, Wound Care Solutions, Pain Management Center for Medication Management, Hanco EMS, BVHS Health Plan and any other entity of BVHS. All of the entities listed will share personal health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

“Personal health information” is individually identifiable health information. This information includes demographics, for example, age, address, e-mail address, and relates to your past, present, or future physical or mental health or condition and related health care services. We are required by law to maintain the privacy of our patients’ personal health information, to provide patients with notice of our legal duties and privacy practices with respect to your personal health information and to notify you in the unlikely event of a breach or unauthorized disclosure of your personal health information. 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 personal health information maintained by us. You may receive a copy of any revised Notices at any of the above listed BVHS locations, electronically at bvhealthsystem.org or a copy may be obtained by mailing a request to Blanchard Valley Health System, Administrative Offices, Attention: Privacy Officer, 1900 S. Main Street, Findlay OH 45840, or by phone 419.423.4500.

USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION

Your Authorization.

Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization. There are certain uses and disclosures of your personal health information for which we will always obtain a prior authorization and these include:

 

• Marketing communications unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health or wellness information, or a communication about health-related products or services that we offer or that are directly related to your treatment.
• Most sales of your health information unless for treatment or payment purposes or as required by law.
• Psychotherapy notes unless otherwise permitted or required by law.

 

Treatment

We will make uses and disclosures of your personal health information as necessary to provide, coordinate or manage your health care and related services. For instance, 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 personal health information 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 you are going to receive home health care after you leave the hospital, we may release your personal health information to that home health care agency so that a plan of care can be prepared for you. In emergencies, we will use and disclose your personal health information to provide the treatment you require.

Payment

We will make uses and disclosures of your personal health information as necessary for the payment purposes of those health professionals and facilities that have treated you or provided services to you. For example, 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. We may also inform your health plan about a treatment you are going to receive to obtain prior approval or determine if your health plan will cover the treatment.

Health Care Operations

We will use and disclose your personal health information as necessary, and as permitted by law, to support the daily activities related to health care operations. These activities may include but are not limited to, clinical quality improvement, professional peer review, business management, training medical students, accreditation and licensing, etc. For example, we may use and disclose your personal health information to medical staff, clinicians or other hospital associates for review and learning to support 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.

We may also contact you to provide appointment reminders, follow up on services provided or to provide test results. We may call you by name in the waiting room when your physician is ready to see you.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits or services that might interest you. For example, your name and address may be used to send you information about services offered by BVHS.

HEALTH INFORMATION EXCHANGE (HIE)

We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by providing written notification to BVHS. For more information on how to opt-out of the HIE, please contact Health Information Services at 419.423.5330.

Business Associates

Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, legal services, technical support, etc. It may be necessary for us to provide personal 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 and security of your information.

Research

In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a research organization 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 has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board or privacy board that 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 personal health information without your consent or authorization. For example, we will release your personal health information:

• for any purpose required by law;
• for public health activities, such as required reporting of disease, injury, birth, death, public health investigations, report reactions to medications or problems with products, notify a person whom may have been exposed to a disease or may be at risk for contracting or spreading a disease;
• suspected child abuse or neglect, as required by law;
• if we believe you to be a victim of abuse, neglect, or domestic violence, as required by law;
• disclosing immunization records to a student’s school but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
• to the Food and Drug Administration if necessary to report adverse events, track products, product defects, to participate in product recalls, conduct post-marking surveillance as required;
• to your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
• to a government oversight agency conducting audits, investigations, or civil or criminal proceedings as required by law;
• as required by a subpoena or discovery request; in some cases you will have notice of such release;
• to law enforcement officials as required by law to report wounds,injuries and crimes;
• to coroners and/or funeral directors consistent with law;
• to arrange an organ or tissue donation from you or a transplant for you;
• 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;
• if you are a member of the military as required by armed forces services; we may also release your personal health information if necessary for national security or intelligence activities;
• to workers’ compensation agencies if necessary for your workers’ compensation benefit determination and other similar legally-established programs; and
• if you are an inmate of a correctional facility, BVHS may disclose for the purposes of the institution being able to provide you with health care; for your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

 

Ohio law requires that we obtain consent from you in many instances before disclosing the performance or results of an HIV test or diagnosis of AIDS or an AIDS-related condition; before disclosing information about mental health services you may have received; and before disclosing certain information to the State Long-Term Care Ombudsman. For full information on when such consents may be necessary, you may contact the BVHS Privacy Officer.

BVHS Directories:

Unless you object, we may disclose in our BVHS directory your name, the location at which you are receiving care, your general condition (e.g. good, fair, etc.), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people who ask for you by name. Only members of the clergy will be told your religious affiliation. This information is provided so your family, friends and clergy can visit you and generally know how you are doing.

Family and Friends Involved In Your Care

Unless you object, we may disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine limited disclosure may be in your best interest, we may share limited personal health information with such individuals without your approval. We may also disclose limited personal health information 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.

 

Fundraising

We may contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt-out” of receiving fundraising materials/communications and may do so by sending your name and address to Blanchard Valley Health Foundation, 1900 S. Main Street, Findlay, OH 45840 together with a statement that you do not wish to receive fundraising materials or communications from us.

 

RIGHTS THAT YOU HAVE

Inspect and Copy Protected Health Information

You may inspect and obtain a copy of your protected health information that is contained in a “designated record set” for as long as we maintain the personal health information. A designated record set contains medical and billing records and any other records that BVHS uses for making decisions about you. You have the right to obtain an electronic copy of your health information that exists in an electronic format and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information. All requests must be made in writing and signed by you or your representative. BVHS may charge you a fee for our labor and supplies in preparing your copy of medical records. This fee is established by Ohio law.

 

This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information.

Amendments to Your Personal Health Information

You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.

Accounting of Disclosures of Your Personal Health Information

You have the right to receive an accounting of certain disclosures made by us of your personal health information for six years prior to the date of your request. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free; you may be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Personal Health Information

You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. If BVHS believes that the restriction is not in the best interest of either party, or BVHS cannot reasonably accommodate the request, BVHS is not required to agree to the requested restriction; however, will attempt to accommodate reasonable requests when appropriate. 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. We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care item or service for which BVHS has been paid in full.

Right to Request Confidential Communications

You may request in writing that we communicate with you using alternative means or at an alternative location. We will not ask you the reason for your request. We will accommodate reasonable requests, when possible.

Breach Notification

In the unlikely event that there is a breach or unauthorized release of your personal health information, you will receive notice and information on steps you may take to protect yourself from harm.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the BVHS Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation against you for filing a complaint.

Obtain a Copy of this Notice

As a patient, you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

Acknowledgment of Receipt of Notice

You will be asked to acknowledge receipt of this Notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

CONTACT INFORMATION

Privacy Officer

You may contact the BVHS Privacy Officer for further information about the complaint process or for further explanation of this document. The BVHS Privacy Officer may be contacted at Blanchard Valley Health System, Administrative Offices, Attention: Privacy Officer, 1900 S. Main Street, Findlay, OH 45840, or by phone at 419.423.4500.

Documents

Documents referred to within this Notice, for example, Requests for Amendment, Restriction, Confidential Communications, Authorization for Uses and Disclosures of Patient Information, Notice of Privacy Practices, etc. can be located at www.bvhealthsystem.org or you may contact the Privacy Officer to obtain a copy of the needed form.

EFFECTIVE DATE

This Notice of Privacy Practices is effective April 14, 2003. Revision dates: 01/10/07; 08/22/13; 5/23/16