Services

NOTICE OF PRIVACY PRACTICES
Keeping Your Personal Health Information (PHI) Private

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 of Privacy Practices” applies to Galion Community Hospital and the Galion Community Hospital Medical Staff. Our health care providers work together to provide the best care to their patients. As allowed by law and only if needed, health information is shared to provide the best treatment, arrange for payment and improve how we provide care in the future. The purpose of this notice is to tell you how we share your information and how you can find out more about our information sharing practices. You may receive this notice in advance of a hospital visit, or you may receive it at the visit location when you arrive. On the consent for treatment form for this visit, you will be asked to acknowledge receipt of this Notice of Privacy Practices.

I. We Have a Legal Duty to Protect Your Personal Health Information (PHI)
By law, we must keep your health information private and tell you that we are doing so. This includes your past, present, or future health information (your condition, care provided to you, or payment). We must follow the terms of this notice. If they change, we will change the notice so you will be aware of the changes. You can get a copy of any revised notice by contacting the Galion Community Hospital Privacy Officer. Contact information is listed in Section V of this notice.

II. We May Use and Disclose (Share) Your Personal Health Information (PHI)
1. For Treatment/Care. We may use and share your PHI for your treatment or care.
For example:

Doctors, nurses, hospital chaplains and other staff involved in your care will use information in your chart (medical record) so that we can provide you with the best care.
If you are being treated for a knee injury, we may share your PHI with the
physical therapy staff so they can help plan your activity.
We may also share your PHI with another health care facility or professional not associated with us but who will be providing treatment or care to you. A specific example, if you leave this hospital to receive home health care, we may share your PHI with that home health care agency so that your treatment and care plan can be prepared for you.

2. For Payment of Your Treatment. We may use and share your PHI if needed for
payment purposes.

For example:

We may share information about your tests and care to your insurance company to arrange payment for services provided to you.
We may use your information to prepare a bill to send to you or to the person responsible for your payment.
We may share your PHI with our business partners who help us with things like billing and claims. These businesses MUST protect the privacy of your information.
For payment purposes, we may share your PHI with other health care professionals who have treated you or provided services to you, even though they may not be associated with us.

3. For Health Care Operations. We may use and share your PHI, as necessary and as permitted by law, to help improve care and operate the hospital (such as improving clinical care, staff evaluations, managing our business, auditing, legal services, accreditation and licensing).

For example:

We may use and share your PHI to evaluate the care the staff provides.
We may need to share PHI with our business partners who help us with our
health care operations. These businesses MUST protect the privacy of your
information.
We may also share your PHI with other health care professionals, facilities and health plans to help them improve their care and operations, but only if they also have a patient-relationship with you.

4. For Fundraising. We may use PHI to raise funds for our hospitals/centers. Money
raised is used to improve and support health care and educational programs that we
provide to the community. We may contact you to donate to a fundraising effort. You
have the right to "opt-out" so that you do not get fundraising information. You can optout by sending your name and address to the Galion Community Hospital Privacy
Officer with a statement that you do not wish to receive fundraising information or
communications.

5. For Appointment reminders and health-related benefits or services. We may use PHI to send appointment reminders or test results.

6. Health Products and Services. We may use your PHI to let you know about our health products and services, those necessary for your care, to tell you of new products and services we offer and to give you general health and wellness information.

7. For workers’ compensation. We may share your PHI to workers' compensation
agencies if needed for a benefit determination.

8. When services are requested by your employer. We may share your PHI with your employer when we have provided care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer.

9. For some government functions. We may share your PHI if needed:

If you are a veteran or in the military.
For national security or security activities, such as protecting the President of the United States or conducting intelligence operations.

10. To avoid harm. We may share PHI to law enforcement or safety staff in order to avoid a serious threat to the health or safety of one person or the public.

11. For research. We may share your PHI for research when it is approved by our
institutional review board with special rules to ensure privacy.

12. For purposes of organ donation. We may share your PHI if needed to arrange for
organ or tissue donation from you or to give a transplant to you.

13. For health oversight activities. By law, we must share your PHI as needed to a
government agency doing audits, investigations, and civil or criminal proceedings.

For example:

We will share information to help the government when it investigates a health care provider or organization.

14. For public health.

We may share your PHI for public health activities, such as reporting diseases, injuries, births, deaths, looking into disease outbreaks and disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition.
For deceased patients, by law and only if needed, we must share your PHI to coroners and funeral directors.

15. For legal cases or law enforcement (at the federal, state and local level). We may share your PHI as needed:

To report wounds, injuries and crimes.
If we suspect child abuse or neglect;
If we believe you are a victim of abuse, neglect, or domestic violence.
To the Food and Drug Administration to report medicine adverse reactions, product defects, or product recalls.
By subpoena or discovery request.
Under court order

16. For Long Term Care: Ohio law requires that we obtain a consent from you before
disclosing your personal health information to the Long Term Care Ombudsman
regarding your stay in our Extended Care Unit.

III. You Have the Chance to Object (“Opt Out”) to the Following Uses and Disclosures:

1. Our Facility Directory. We have a facility directory (a combination of reports) listing the name, room number, room phone number, general condition and religion of each
patient. This information is only shared with clergy or people (visitors/callers) who ask
for you by name. If you request to be on the “Do Not Announce” list and sign the
consent form, your hospital information will not be released.

2. Family and Friends Helping In Your Care. With your approval, we may share your
PHI with your family, friends, or other caregivers who help with your care or payment of
your care. We may share PHI to an agency that is helping in disaster relief efforts so
that they may find your family or caregiver.

3. All Other Uses and Disclosures Need Your Prior Written Authorization. In any
situation not mentioned in section II or III, we will ask for your written authorization
before using or sharing your PHI. If you sign an authorization form, you can later cancel that authorization (in writing) to stop any future uses.

IV. Your Rights Regarding Your PHI

1. The Right to Access Your Own PHI. You have the right to copy and look at most of
your PHI that we keep on your behalf.

All requests to copy and look at your PHI must be made in writing and signed by you or your legal representative. You may get an access request form from the Medical Records department.
If there is a cost, we will tell you in advance. We may charge you for copying the PHI, postage (if mailed) and/or a summary or explanation of the PHI.

2. The Right to Change your PHI. If you think there is a mistake in your PHI or that
information needs to be added, you can request that we amend (change) your PHI.

You must make a written request and state your reason for amending your PHI. Contact the Medical Records department for an amendment form.
If we approve your request, we will place the amendment form in your medical record, tell you that we have done it, and tell others who need to know about the change.

3. The Right to a Listing of Certain Disclosures of Your PHI. You have the right to get a list of when we shared your PHI and to whom.

The list will include:

the date and to whom (with the address, if known) PHI was disclosed
the reason and type of PHI shared.

This list will not include disclosures:

made for treatment, payment, health care operations, or directly to you, to your family, or in our facility directory,
that you have already authorized in writing
for national security purposes,
for corrections or law enforcement staff, or
before April 14, 2003.

Written requests must be signed by you or your legal representative. Contact the
Medical Records department for an accounting request form

The first list in any 12-month period is free. You may be charged for each extra list you request in the same 12-month period.

4. The Right to Ask For Limits on Using and Sharing Your PHI. You have the right to ask that we limit how we use and share your PHI for treatment, payment, or health care operations. You may not limit the uses that we are allowed to do by law.

We are not obligated to agree to your request but we will try to abide by your request.
We have the right to end an agreed-to limitation if we believe that ending it is needed or that the limit will be hard to complete. You will be informed.
You can end an agreed-to limit by sending a written termination notice (signed by you or your legal representative) to the Medical Records department.

5. The Right to Choose How We Send PHI to You. You have the right to ask that we
send information on you to a different address or in a different method (e.g. via phone,
e-mail). We must agree to your request as long as it can easily be done.

V. How to Complain About Our Privacy Practices.

If you feel your privacy rights have been violated, or you disagree with a decision we made about access to your PHI, you may file a complaint in writing or by calling the:

Galion Community Hospital Privacy Officer (see contact information below).
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. within 180 days of a violation of your rights. We will take no retaliation if you file a complaint.

For More Information About This Notice. If you have questions or need further help
with this Notice, you may contact or write to the Galion Community Hospital Privacy
Officer, 269 Portland Way South, Galion, OH 44833 (419-468-0526) or
e-mail: privacyofficer@galionhospital.org.

As a patient, you have the right to get a paper copy of this Notice of Privacy Practices, even if you have asked for a copy by e-mail or other means.

VI. Acknowledgement of Receipt of Notice. You will be asked to acknowledge receipt of this Notice of Privacy Practice on the hospital’s general consent form.

VII. Effective Date
This Notice of Privacy Practices is effective April 14, 2003.