Dear Client:

Welcome to Elyria City Health District. We wanted you to know that we are required by federal law to give you the following document. It is called a Notice of Privacy Practices. We are also required to have you sign our consent form because it contains a written acknowledgement that you have received this document (the acknowledgement may be incorporated in other consents you are required to sign). We realize this document is long so we have provided an index of this notice, which describes how we use and disclose medical information and how you can get access to this information. Please read it carefully.

By law, we are required to:

• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and;
• follow the terms of the notice that is currently in effect.

Thank you again for being our client. Please do not hesitate to contact us if you have any questions.

I. Who will Follow This Notice

II. Our Pledge Regarding Medical Information

III. How We may Use and Disclose Information About You

A. General Usage

1. For Treatment
2. For Payment
3. For Health Care Operations
4. Appointment Reminders
5. Phone Contacts
6. Email
7. Treatment Alternatives
8. Health-Related Benefits and Services
9. Patient Directory
10. Research
11. Entities Involved in Your Care or Payment for Your Care
12. Business Associates
13. To Avert a Serious Threat to Health or Safety
14. As Required by Law

B. Special Situations

1. Military and Veterans
2. Worker’s Compensation
3. Work-Related Injuries
4. Public Health Risk
5. Health Oversight Activities
6. Administration of Government Programs
7. Lawsuits and Disputes
8. Law Enforcement
9. Coroners, Medical Examiners, and Funeral Directors
10. National Security and Intelligence Activities
11. Protective Services for the President and Others
12. Inmates

IV. Your Rights Regarding Medical Information About You

1. Right to Inspect and Copy
2. Right to Amend
3. Right to an Accounting of Disclosures
4. Right to Request Restrictions
5. Right to Reasonable Accommodations
6. Right to a Paper Copy of This Notice

V. Changes to This Notice

VI. Contact

VII. Complaints

VIII. Other Uses of Medical Information

If you have any questions about this notice, please contact the Privacy Officer at 323-7595.

I. WHO WILL FOLLOW THIS NOTICE

This notice describes our department’s practices and that of:

• Any health care professional authorized to enter information into your records;
• Any member of a volunteer group we allow to assist in the receipt of services;
• All employees, staff and other personnel;
• Elyria City Health Department and programs directed by the health department, including but not limited to, Help Me Grow; Bureau for Children with Medical Handicaps; Medicaid Outreach; Immunization program; Well Child program; Prenatal program; Travel clinic; Ohio Infant Mortality and Reduction Initiative program; etc… will follow this privacy notice. In addition, these entities, may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

II. OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from the department. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all medical records of your care generated by the department, whether made by health department personnel or contracted professionals. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

III. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

A. General Usage

1. For Treatment: Treatment generally means the provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a client, or the referral of a client from one health care provider to another. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other professionals who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different divisions and programs of the health department also may share medical information about you in order to coordinate the different things that you need, such as prescriptions, lab work, and x-rays. We also may disclose medical information about you to people outside the health department who may be involved in your medical care after you leave the health department, such as family members, or others we use to provide services that are part of your care. 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 instance, if, after you leave the health department, you are going to receive hospital or home health care, we may release your personal health information to that home health care agency so that a plan of care can be prepared for you.
2. For Payment: Payment encompasses the various activities of health care providers to obtain payment or be reimbursed for their services and of a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for the provision of health care. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at the health department so your health plan will pay for the service. We may also tell your health plan about a treatment you are going to receive to obtain for prior approval or to determine whether your plan will cover the treatment. We may use your information to prepare a bill to send to you or the person responsible for your payments.
   
   Common payment activities include, but are not limited to:
   • Determining eligibility or coverage under a plan and adjudicating claims;
   • Risk adjustments;
   • Billing activities;
   • Reviewing health care services for medical necessity, coverage, justification of charges, and the like;
   • Utilization review activities, including pre-certification and preauthorization and
   • Disclosures to consumer reporting agencies (limited to specified identifying information about the individual, his or her payment history, and identifying information about the ECHD).
3. For Health Care Operations: Health Care Operations are certain administrative, financial, legal, and quality improvement activities of ECHD that are necessary to run its business and to support the core function of treatment and payment. We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run our facility and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many health department patients to decide what additional services the health department should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other health department personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health departments to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. We may also use and disclose information for accreditation, licensing, and case management.
   
   These activities include, but are not limited to:
   • Conducting quality assessment and improvement activities, population based activities relating to improving health or reducing health care costs, and case management and care coordination;
   • Reviewing the competence or qualifications of health care professionals, evaluating provider and health plan performance, training health care, and non-health care professionals, accreditation, certification, licensing, or credentialing activities;
   • Underwriting and other activities relating to the creation, renewal, or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to health care claims;
   • Conducting or arranging for medical review, legal, and auditing services, including fraud and abuse detection and compliance programs’
   • Business planning and development, such as conducting cost-management and planning analyses related to managing and operating the entity’ and
   • Business management and general administrative activities, including those related to implementing and complying with the privacy rule and other administrative simplification rules, customer service, resolution of internal grievances, sale or transfer of assets, creating de-identified health information or limited data set, and fundraising for the benefit of the ECHD.
4. Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the health department.
5. Phone Contacts: We may also contact you by phone to provide you with test results, return your call, answer questions, obtain additional information on billing, or other related issues. If you are not in, we will only leave our name, the name of our health department, and our phone number, for confidentiality reasons.
6. Email: We may respond or contact you with email if you have consented to such (contacting us via email first constitutes tacit consent).
7. Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
8. Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
9. Patient Directory: This information may include your name, and your presence in the facility. We will not disclose your presence in the building. We will take the name of the person requesting information about your whereabouts and provide it to you for your information.
10. Research: In limited circumstances, we may use and disclose your protected health information for research purposes. For example, a research organization may wish to compare outcomes of all clients who received specific services in a given time period 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 which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.
11. Entities Involved in Your Care or Payment for Your Care: We may release medical information about you to an entity who is involved in your medical care or who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so your family can be notified about your status and location.
12. Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, laboratory, etc. At times it may be necessary for us to provide certain 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 of your information. Business Associates are also required by law to protect your confidentiality and privacy and they sign a contract to this effect.
13. To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
14. As Required By Law. We will disclose medical information about a client when required to do so by federal, state, or local law.

B. SPECIAL SITUATIONS

1. Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
2. Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs, if necessary, for your benefit determination for work-related injuries or illness. If you have a work-related injury, your health information will be forwarded for processing of workers' compensation claims, if applicable.
3. Work-Related Injuries: If you have a work-related injury, your health information will be forwarded to your employer, with your permission.
4. Public Health Risk: We may disclose medical information about you for public health activities. These activities generally include, but are not limited to, the following:
   1. to prevent or control disease, injury or disability;
   2. to report births and deaths; injury, cancer surveillance, immunizations, and for required public health investigations;
   3. to report child abuse or neglect, elder abuse or neglect, domestic violence if serious physical injury is present;
   4. to report reactions to medications or problems with products;
   5. to the Victims of Crime Division, at the State Attorney General’s Office, to help you get financial assistance if you have been the victim of a crime or sexual assault;
   6. to notify people of recalls of products they may be using; and to the Food and Drug Administration to report adverse events or product defects;
   7. to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
   8. to report suspicious injury and burns, as required by law;
   9. to release information to your employer when we have provided health care to you at the request of your employer.
      
      Ohio law requires that we obtain an authorization from you before disclosing the performance or results of an HIV test or diagnosis of AIDS or an AIDS-related condition.
5. Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
6. Administration of Government Programs: We may disclose PHI relating to eligibility for or enrollment in the health plan to another agency administering a government program providing public benefits if the sharing of eligibility or enrollment information among such agencies or the maintenance of such information in a single or combined data system accessible to all such agencies is required or expressly authorized by statute or regulation. We may also disclose PHI relating to the program to another government program providing public benefits if the programs serve the same or similar populations and the disclosure of PHI is necessary to coordinate the covered functions of such programs or to improve administration and management relating to the covered functions.
7. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
8. Law Enforcement: We may release medical information if asked to do so by a law enforcement official:
   1. In response to a court order, subpoena, warrant, summons or similar process;
   2. To identify or locate a suspect, fugitive, material witness, or missing person;
   3. About the victim of a crime, if under certain limited circumstances, we are unable to obtain the person’s agreement;
   4. About a death we believe may be the result of criminal conduct;
   5. About criminal conduct at an organization; and
   6. 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.
9. Coroners, Medical Examiners and Funeral Directors: We may release medical 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 medical information about patients to funeral directors as necessary to carry out their duties.
10. National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
11. Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
12. Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

IV. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

1. Right to Inspect and Copy: You have the right to inspect and request a copy of your medical information that may be used to make decisions about your care. This usually includes medical billing and records, but does not include psychotherapy notes.
   
   To inspect and request a copy of your medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. This fee is set by Ohio law.
   
   We may deny your request to inspect and obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the health department will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
2. Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. An amendment does not mean that information will be removed. You have the right to request an amendment for as long as the information is kept by our facility.
   
   To request an amendment, your request must be made in writing and submitted to the Privacy Officer on our designated forms. In addition, you must provide a reason that supports your request.
   
   We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
   1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
   2. Is not part of the medical information kept by or for the health department;
   3. Is not part of the information which you would be permitted to inspect and copy; or
   4. Is accurate and complete.
3. Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you.
   
   To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. This does not include an accounting for disclosures made for treatment, payment and health care operations.
4. Right to Request Restrictions: You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information 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 the information is needed to provide you emergency treatment.
   
   To request restrictions, you must make your request in writing to the Privacy Officer on our designated forms. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
5. Rights to Reasonable Accommodations: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
   
   To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
6. Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
   
   You may view this notice at our website: www.elyriahealth.com
   
   To obtain a paper copy of this notice, contact the Privacy Officer.

V. CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical 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 the health department. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the health department for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

VI. CONTACT

Contact the Privacy Officer at 440-323-7595 if you have any questions about the notice or for further information.

VII. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the health department or with the Secretary of the Department of Health and Human Services. To file a complaint with the health department, contact the Health Commissioner or the Privacy Officer at 440-323-7595. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

VIII. OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical 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 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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE: You will be asked to sign an acknowledgement form that you received this Notice of Privacy Practices.