Alvis House
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.
¨
For Treatment. We may use health information about you to
provide you with treatment. We may
disclose your health information to physicians, nurses, counselors and other
employees who are involved in your care.
We may also use or disclose your health information to manage your
treatment, by, for example, disclosing your health information to another
provider to whom we have referred you for a diagnosis.
¨
For Payment. We may use and disclose your health
information to bill and collect for the treatment and services we provide to
you. We may send your health
information to an insurance company or other third party for payment purposes
including to a collection service. For
example, we may include information with a bill to a third-party payer that
identifies you, your diagnosis, procedures performed, and supplies used in
rendering the services.
¨
For Health Care
Operations. We may use and disclose your health
information for health care operations.
These uses and disclosures are necessary to run Alvis House and to ensure
that you receive quality health care. For
example, we may use medical information about you to review and evaluate our
treatment and services or to evaluate our staff’s performance while caring for
you. In addition, we may disclose your
health information to third-party business associates who perform services for Alvis
House.
¨
As Required By Law. We will disclose your health information
when required to do so by federal, state or local law.
¨
For Public Health Purposes. We may disclose your health information for
public health activities, including, but not limited to the following:
·
Preventing
or controlling disease, injury or disability;
·
Notifying
people of recalls of products they may be using; and
·
Notifying
a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition.
¨
About Victims of Abuse.
We may disclose your
health information to notify the appropriate government authority if we believe
an individual has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
¨
Health Oversight
Activities. We may disclose your health information to a
health oversight agency for activities authorized by law. These oversight activities might include
audits, investigations, inspections, and licensure.
¨
Judicial Purposes. We may disclose your health information in
response to a court or administrative order.
We may also disclose your health information in response to a subpoena,
discovery request, or other lawful process by someone else involved in a
dispute, but only if efforts have been made to tell you about the request, in
which you were given an opportunity to object to the request, or to obtain an
order protecting the information requested.
¨
Law Enforcement. We may release health information if asked
to do so by a law enforcement official, if such disclosure is:
·
Required
by law or in response to a court order, subpoena, warrant, summons or similar
process;
·
To
identify or locate a suspect, fugitive, material witness, or missing person;
·
About
the victim of a crime if, under certain limited circumstances, we are unable to
obtain the person's agreement;
·
About
a death we believe may be the result of criminal conduct;
·
About
criminal conduct at Alvis House; or
·
In
emergency circumstances to report a crime; the location of the crime or
victims; or the identity, description or location of the person who committed
the crime.
¨
Coroners, Medical
Examiners and Funeral Directors. In
certain circumstances, we may disclose health information to a coroner or
medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of
death. We may also release health
information about individuals to funeral directors as necessary to carry out
their duties.
¨
Organ and Tissue Donation. We may disclose your health information to
organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to facilitate organ
or tissue donation and transplantation.
¨
Research.
Under certain
circumstances, we may use and disclose health information about you for
research purposes.
¨
To Avert a Serious Threat
to Health or Safety. We may use and
disclose your health information when we believe it is necessary to prevent a
serious threat to your health and safety or the health and safety of the public
or another person. Any such disclosure would
only be to someone able to help prevent or lessen the threat or to law
enforcement authorities.
¨
Military and Veterans. If you are a member of the armed forces, we
may release your health information as required by military command
authorities.
¨
National Security and
Intelligence Activities. We may release
your health information to authorized federal officials for lawful intelligence
and other national security activities authorized by law.
¨
Protective Services for
the President and Others. We may disclose
your health information to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state
or for the conduct of special investigations.
¨
Custodial
Situations. If you are an inmate in a correctional institution
and if the correctional institution or law enforcement authority makes certain
representations to us, we may disclose your health information to a
correctional institution or law enforcement official.
¨
Workers' Compensation.
We may disclose your health
information as authorized by and to the extent necessary to comply with
workers' compensation laws or laws relating to similar programs.
¨
Treatment Alternatives,
Appointment Reminders and Health-Related Benefits. We may use and disclose your health information
to tell you about or recommend possible treatment alternatives or
health-related benefits or services that may be of interest to you. In addition, we may use and disclose your
health information to provide appointment reminders. If you do not wish us to contact you about treatment
alternatives, health-related benefits or appointment reminders, you must notify
us in writing, and state which of those activities you wish to be excluded
from.
¨
Individuals Involved in
Your Care or Payment for Your Care. We may
release health information about you to a family member, other relative, or any
other person identified by you who is involved in your health care. We may also give information to someone who
helps pay for your care.
¨
Third Parties. We may disclose your health information to
third parties with whom we contract to perform services on our behalf. If we disclose your information to these
entities, we will have an agreement by them to safeguard your information.
OTHER USES
OF HEALTH INFORMATION
Other uses and
disclosures of health information not covered by this Notice or the laws that
apply to us will be made only with your written authorization. If you provide us authorization to use or
disclose your health information, you may revoke that authorization, in
writing, at any time. If you revoke
your authorization, we will no longer use or disclose health information about
you for the reasons covered by your written authorization.
You understand that we are unable to take
back any disclosures we have already made under the authorization, and that we
are required to retain our records of the care that we provided to you.
SENSITIVE HEALTH
INFORMATION
Certain
heath information, including, but not limited to drug and alcohol abuse
treatment records, HIV testing and AIDS information, and mental health records
are subject to different standards for use and disclosure under federal and/or
state law. Alvis House will abide by the
more stringent standard when applicable.
YOUR
RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following
rights regarding health information we maintain about you. In order to exercise these rights, you
must make the request in writing to Alvis House, 1991 Bryden Road, Columbus,
Ohio 43205, Attn: Ramona Swayne,
(614) 252-8402.
¨
Right to Request
Restrictions. You have the right to request a restriction
or limitation on the health information we use or disclose about you for
treatment, payment or health care operations.
You also have the right to request a limit on the health information we
disclose about you to someone who is involved in your care or the payment for
your care. Requests for a restriction
must be made in writing.
We are not
required to agree to your request. If we do agree, we will comply with your
request unless the information is needed to provide you emergency treatment.
¨
Right to Request
Confidential Communications. You
have the right to request that we communicate with you or your responsible
party about your health care in an alternative way or at a certain location. Requests for confidential communications
must be made in writing.
¨
Right to Inspect and Copy. You have the right to
inspect and copy health information that may be used to make decisions about
your care. Requests for access must be
made in writing.
¨
Right to Amend. You have the right to ask us to amend your
health and/or billing information for as long as the information is kept by us. Requests for amendment must be made in
writing.
¨
Right to an Accounting of
Disclosures. You have the right to request a list of
certain disclosures that we have made of your health information. Requests for accounting must be made in
writing.
¨
Right to a Paper Copy of
This Notice. You have the right to a paper copy of this
Notice.
WHO THIS
NOTICE APPLIES TO
This Notice describes Alvis House’s practices and those
of all employees, staff and other personnel.
CHANGES TO
THIS NOTICE
We reserve the right to
change this Notice. We reserve the
right to make the revised Notice effective for health information we already
have about you as well as any information we receive in the future. We will post a copy of the current Notice in
a clear and prominent location to which you have access.
COMPLAINTS
If you believe your
privacy rights have been violated, you may file a complaint with Alvis House or
with the U.S. Secretary of Health and Human Services. To file a complaint with us, write: Alvis House, 1991 Bryden Road, Columbus, Ohio 43205, Attn: Ramona Swayne, (614) 252-8402.
You will not
be penalized for filing a complaint.
EFFECTIVE
DATE
The effective date of this Notice is April
14, 2003.