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Galion City Health Department
Notice Regarding the Use and Disclosure of
Protected Health Information
Effective July 1, 2003
This notice has been prepared by the Galion City Health Department to
comply with HIPAA requirements. It explains how Protected Health
Information about you can be created, shared, protected and maintained.
What is my Protected Health Information?
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Anything from the past, present or future;
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Anything about your mental or physical
health condition;
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Any information that is spoken, written or
electronically recorded, and is; created by or given to anyone
providing care to you; a health plan; a public health authority; your
employer; your insurance company; your school or university; or anyone
who processes health information about you.
What
rights do I have about my Protected Health Information?
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You have the right to consent to the use
and disclosure of your Protected Health Information for the limited
purpose of diagnosing you and administering and paying for your
treatment.
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You have the right to authorize the
sharing of your Protected Health Information for other purposes.
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You have the right to see and copy your
Protected Health Information. Exceptions to this information are
personal psychotherapy notes; information prepared for certain legal
proceedings, and information maintained by clinical laboratories.
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You have the right to request that we
amend your Protected Health Information.
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You have the right to be informed about
and to share your Protected Health Information in a confidential manner
chosen by you. The manner you choose must be possible for us to do.
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You have the right to restrict how we use
and disclose your Protected Health Information. We do not have to agree
to your restrictions. If we do agree, we must follow your restrictions.
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You have the right to obtain a copy of a
record of certain disclosures of your Protected Health Information that
we make. If you request a copy of the information, we may charge a
reasonable fee for the costs of copying, mailing or other supplies
associated with your request.
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You have the right to have a copy of this
Privacy Notice. We may change the terms of this Privacy Notice from
time to time. You can always get a copy of the current Privacy Notice
by requesting it.
Consent
What can be done with my
information if I consent to disclose it for my diagnosis or to administer
and pay for my treatment?
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With your consent, we can share
information about your case with other professionals so that you can
receive the best possible treatment.
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With your consent, we can share
information about when and for what purpose you were seen, so that we
can be paid for treating you. For example, we could send a form to your
insurance company when and for what condition you were at the office.
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With your consent, we can share
information with other health care providers to make sure that you
obtain the correct diagnosis.
Can I revoke my consent?
Yes. You can revoke your consent. You must do this in writing and
bring it to us so that we can stop using and disclosing your Protected
Health Information. We are permitted to use and disclose your Protected
Health Information based on your consent until we receive your
revocation in writing. However, if you revoke your consent, we reserve
the right to refuse to further provide treatment to you, on the basis
of your refusal to allow us to share our information for purposes of
treatment, payment, and healthcare operations.
Authorization
What can be done with my
information if I authorize its disclosure for other purposes?
With your permission, we can share your Protected Health Information for
reasons other than to diagnose you and to administer and pay for
treatment.
Can I Revoke My Authorization?
Yes. You can revoke your
authorization. You must do this in writing and bring it to us so that we
can stop sharing your Protected Health Information. We are permitted to
share your Protected Health Information based on your authorization
until we receive your revocation in writing.
Are there any circumstances when my
information can be shared without my consent or authorization?
Yes. Your Protected Health
Information can be shared without your prior consent or authorization in
the following situations:
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In an emergency so long as consent is
obtained as soon as possible;
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When required by law:
– For public health activities;
– To protect victims of abuse, neglect, or domestic violence;
– For law enforcement purposes;
– To avert serious threats to health or safety;
– Internal consultations among Galion Health Department staff, and
quality assurance.
What about any other uses of my Protected
Health Information?
Other uses and disclosures of
your Protected Health 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 you 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.
What will you do to protect my Protected
Health Information?
We will maintain the privacy of
your Protected Health Information as required by law. At your request, we
will provide you with a Privacy Notice containing our legal
responsibilities and privacy practices regarding Protected Health
Information.
We will follow the terms of the Privacy Notice currently in effect.
We reserve the right to change the terms contained in this Privacy
Notice. If we do this, it will affect all Protected Health Information
maintained by us. We will notify you that we have changed the Privacy
Notice by posting it at our office. Copies of changes are available upon
request.
What can I do if I have questions or want
to complain about the use and disclosure of my Protected Health
Information?
All questions and complaints
about the use and disclosure of your Protected Health Information may be
sent to:
Director of Nursing
Galion City Health Department
113 Harding Way East
Galion, OH 44833
(419) 468-1075
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