HIPAA Requirements

Notice of Privacy Practices: This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.


Understanding Your Health Information

Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as:

• Basis for planning your care and treatment.
• Means of communication among the many health professionals who contribute to your care.
• A legal document describing the care you received.
• Means by which you or a third-party payer can verify that services billed were actually provided.
• A tool in educating health professionals.
• A source of data for medical research.
• A source of information for public health officials charged with improving the health of the nation.
• A source of data for facility planning and marketing.
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.


Understanding what is in your record and how your health information is used helps you to:

• Ensure its accuracy.
• Better understand who, what, when, where and how of health information.
• Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522.
• Obtain a paper copy of the notice of information practices upon request.
• Inspect and copy your health record as provided for in 45 CFR 164.524.
• Amend your health record as provided in 45 CFR 164.526.
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528.
• Request communications of your health information by alternative means or at alternative locations.
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

This organization is required to:

• Maintain the privacy of your health information.
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
• Abide by the terms of this notice.
• Notify you if we are unable to agree to a requested restriction.
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our privacy practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post an updated copy in the lobby at the Welcome Center and on our website. A copy will also be provided to you at your request. We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact our HIPAA Privacy Officer at 614-559-0247. If you believe your privacy rights have been violated, you may file a complaint with our Compliance Officer on our confidential hotline at 614-559-0316 or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment. For example: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to the treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from this facility. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Uses or Disclosures

Business Associates

There are some services provided in our organization through contacts with business associates. Examples include laboratory services, pharmacy services, ambulance services and radiology services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.


Unless you notify us that you object, we will use your name and location in the facility for directory purposes. This information may be provided to all people who ask for you by name.


To maintain your spiritual well-being, we may notify your religious congregation of your admittance to the facility. You have the right to refuse such notification.


We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care, your location and general condition.

Communication with Family

Health professionals, using their best judgment, may disclose to a family member or relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.


We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral Directors

We may disclose health information to funeral directors consistent with applicable law to carry out their duties.


Unless you notify us that you object, we may contact you and your family to provide information about other health-related services that may be of interest to you. We may approach you to participate, with your permission, in marketing materials. No health information will be used without your permission.


Unless you notify us that you object, we may contact you and your family, using limited health information such as your name and address, as part of a fundraising effort. No health information will be used without your permission.

Food and Drug Administration (FDA)

We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.

Workers Compensation

We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health

As required by law, we may disclose your health information to public health or legal authorities charged with preventing/ controlling disease, injury, abuse, neglect or disability. Law Enforcement We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

Health Oversight Agencies

We may use or disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities. The oversight activities may include audits, investigations, inspections or licensure, and certification surveys. These activities are necessary for the government to monitor the persons or organizations that provide healthcare to individuals and to ensure compliance with applicable state and federal laws and regulations.

Emergency Situations

Health information may be disclosed in the event of emergency situations; protected health information may be released as follows: (1) The treatment of patients; (2) To identify, locate and notify family members and certain others (i.e. The American Red Cross) of the patient’s condition, location or death; (3) To prevent/lessen threats to health or safety.