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.
 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please read it carefully!
 

When You Receive Care

When you get care at Community Health & Wellness Partners (CHWP) health center, your caregivers create a medical record. The medical record has information about your medical history, the tests you had, the care you received, and how you responded. We also have billing records.

We are required by law to make sure your medical information is kept private, to give you this Notice to tell you how we use and share your medical information, and what your rights are. We will ask for your signature to verify that you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name and date.
 

I. How We May Use and Disclose Health Information About You

Information we can share without your permission.

We may use medical information about you to provide you with treatment. People who care for you need to know about your health problems so that they can give you safe and complete care. These people include doctors, nurses, health students/residents/interns, home health agencies, nursing homes, laboratories, hospitals, equipment providers, or others we use to help provide services that are part of your ongoing care.
 

Some examples of how we use and share information are:

• If you have diabetes, the nutritionist needs to know this to help you plan safe meals.
• If you are admitted to the hospital, we may share information with the hospital to help with your care.
 

We may share medical information about you so that we can get paid for your care. For example, we may share your information with your insurance company so that we get paid for your health care. We may also share it to get an okay from your insurer before you receive a certain treatment (prior approval). That way, we know they will pay for your care. If you are being treated for a substance use disorder, we will require a release to provide information for payment purposes.
 

We may disclose your health information with third parties such as your health insurance company in joint activities that include utilization review, quality assessment and improvement activities.
 

We may use and share medical information about you as part of improving care to all patients. For example, to train doctors or other healthcare workers and students, or to look at how your care went and how we can improve care in the future. We may also combine health information about many patients to see where we can make improvements.
 

We may use or share information about you because you get care here:

• To tell someone who helps pay for your care;
• To tell your relatives, close friends or others involved in your care, but only if you say it is okay for us to share this information. If you are unable to say it is okay, we will do what we think is in your best interests;
• To tell you about treatment alternatives or to tell you about other health related benefits and services available to you;
• To let health oversight agencies make sure we are following the rules of programs like Medicare or Medicaid;
• To give you marketing materials when we are face-to-face; or when we tell you about our products or services for your care or treatment;
• You can always opt-out of receiving marketing or fundraising materials from us;
• We will require your authorization to provide marketing information from third-party companies.
 

Public Health Activities

We share information for public health activities. For example, we may disclose information about you to:

• Prevent or control disease, injury, or disability;
• Report births and deaths, child abuse or neglect, domestic violence, and reactions to medications or problems with products;
• Notify people of recalls of products they may be using;
• Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
 

Legal Reasons

We share information for legal reasons.

• When we must respond to a legal order or other lawful process. If there is a subpoena, discovery request or other lawful process by someone else involved in a dispute, we will release information only if efforts have been made to tell you about the requests or to obtain an order protecting the information requested;
• When we are required by law to tell the police or other law enforcers, or when we are required by a grand jury or subpoena to:

• Report certain injuries, as required by law gunshot wounds, burns, injuries to perpetrators of crime;
• Help identify or locate a suspect, fugitive, material witness, or missing person;
• Report about the victim of a crime if, under certain limited circumstances, we are unable to obtain the agreement;
• Report about a death we believe may be the result of criminal conduct;
• Report about criminal conduct at our facility; and
• In emergency circumstances to report a crime.
 

Other Uses and Disclosures

We also use and share information with:

• Donor programs, if you are donating or in need of an organ, eyes, or tissues;
• Medical examiners or coroners to help identify a body or find the cause of death; or
• Funeral directors to help them carry out their duties.
 

We may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information. All projects are evaluated to assure that they will be of direct or indirect benefit to our patients and/or community and must be approved by the CHWP Board of Directors. We may disclose health information about you to people preparing to conduct a research project; for example, to help them look for patients with specific health needs.
 

We may also use and share information about you:

• To prevent or lessen a serious threat to you or others;
• If you are in the military, as required by military rules;
• If you are an inmate, to the correctional institution or law enforcement officials for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution;
• To report findings from an examination ordered by the court; or
• To follow the laws for national safety reasons;
• We use and share information as required by other laws not mentioned above.
 

Information we may use or share only if you give us written permission

For any purpose not mentioned above.

Most uses and disclosures of psychotherapy notes and uses and disclosures of Protected Health Information (PHI) for marketing purposes.
 

To use or share any Highly Confidential Information. We follow federal and state laws that require special privacy protections when we use or share this type of information. For instance, medical information about communicable disease, HIV/AIDS, and evaluation and treatment related to addiction services or for a serious mental illness is treated differently than other types of medical information. For those types of information, we are required to get your permission before disclosing that information to others in many circumstances including payers.
 

Information we may not share

We may not share results of genetic testing for insurance underwriting purposes. We will not sell your health information.
 

II. Your Rights Regarding Health Information About You

You have the right to look at your own medical information and to get a copy of that information. This includes medical and billing records. You must sign a request form that you can get from the Medical Records Department. If you want additional copies, we will charge a reasonable fee for them. You can look at your record at no cost. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. Electronic medical records are available by accessing the secure Healow portal. No record request form is required when gaining access to your healthcare information.
 

You can ask us to make changes to your record if you think what we have is wrong or not complete. You must put your request in writing and give a reason why you want to make the changes. We will make the changes unless we believe that the information you want changed is complete and accurate, or if the information was not created by us.
 

You can ask for a list of anyone we shared information with and when we shared it, except for information disclosed for treatment, payment, or health care operations, or for those disclosures you specifically authorized. You have to ask for this in writing. Your request must tell us a specific time period (beginning after July 1, 2014) of not more than six years. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year.
 

You can ask us, in writing, to limit who gets information about you. For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse 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 there is an emergency reason we need to share this information.
 

You have the right to ask us, in writing, to send information to you at a different address or contact you in a different way. For example, you may ask us to send information to your work address or a post office box instead of your home address. You do not need to tell us the reason for this. We do not have to comply with your request if it is unreasonable.
 

If you signed an authorization, you could withdraw the authorization. You must sign a form to do this. We cannot do anything about information we already may have shared, but we will not share any more after you give us the signed form.
 

You can ask for a paper copy of this Notice at any time.
 

You have a right to file a complaint if you believe your privacy rights have been violated. You may file this complaint, in writing, with us or with the Secretary of the Department of Health and Human Services. Making a complaint will not change how we treat you.
 

You have a right to be notified of a breach of your PHI. If we give your PHI to any entity for any reason not discussed in this Notice, we will notify you.

If you are paying out-of-pocket for a service you may request that we not disclose PHI related to that service, as long as we are not required by law to disclose.
 

Fundraising. Unless you request us not to, we will use your name and address to support our Fund-raising or Marketing efforts. We may use your name and address to provide you with information about services available at our practice. If you do not want to participate in Fund-raising or Marketing efforts, please check off the following boxes on the HIPAA form.
 

Community Health & Wellness Partners Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices outlined in this notice. In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to inform patients and the office of civil rights of the breech within the timeframe provided by HIPAA law.
 

III. Applicability, Changes to this Notice, Contact Information, and Effective Date

This Notice applies to all of your medical information maintained by CHWP, whether it is information we created or that we received from somewhere else. We reserve the right to change the terms of the Notice. Your privacy rights may change if the laws change. When that happens, we will change the Notice and post it where you will be able to read it. The new Notice will be used for all the information we have about you. We must follow the terms of the Notice that is currently in effect. You can also get a copy of the new Notice, or, if you have any questions about this Notice, please contact Quality/Risk or Compliance/Safety Manager at CHWP 212 E Columbus Ave, Bellefontaine, Ohio 43311
Phone number: 937-599-1411 ext. 215 or ext. 282.