Executive Health Evaluations - Privacy Practice

The terms of this Notice of Privacy Practices apply to the Kettering Medical Center Network, our hospitals, Kettering Medical Center, Grandview Hospital, Southview Hospital, and Sycamore Hospital, as well as our clinics and health centers, operating as a clinically integrated health care arrangement and the physicians and other licensed professionals seeing and treating patients at each service location. A complete listing of our service locations is available upon request. The members of this clinically integrated health care arrangement work and practice at some or all of the service locations. All of the entities and persons listed will share personal health information of patients as necessary to carry out treatment, receive payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of the Notice Of Privacy Practices as necessary and to make the new Notice effective for all personal health information maintained by us. You may receive a copy of any revised notices at any service location or a copy may be obtained on the web at www.kmcnetwork.org or by mailing a request to the Privacy Officer.

USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.

Uses and Disclosures for Treatment
We will make uses and disclosures of your personal health information as necessary for your treatment. For instance, doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, test, etc. 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. And if after you leave the hospital, you are going to receive 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.

Uses and Disclosures for Payment
We will make uses and disclosures of your personal health information as necessary for the payment purposes of those health professionals and facilities that have treated you or provided services to you. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment.

Back to Top

Uses and Disclosures for Health Care Operations
We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your personal health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.

Our Facility Directory
We maintain a facility directory listing the name, room number, and, if you wish, your religious affiliation. Unless you choose to have your information excluded from this directory, the information, excluding your religious affiliation, will be disclosed to anyone who requests it by asking for you by name. This information, including your religious affiliation, may also be provided to members of the clergy. You have the right during registration to have your information excluded from this directory.

Family and Friends Involved In Your Care
With your approval, we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individual’s without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Back to Top

Business Associates
Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide certain of your personal 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.

Fundraising
We may contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt-out” of receiving fundraising materials/communications and may do so by sending your name and address to the Privacy Officer together with a statement that you do not wish to receive fundraising materials or communications from us.

Appointments and Services
We may contact you to provide appointment reminders or test results. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. You may request such confidential communications in writing and may send your request to the Privacy Officer.

Back to Top

Health Products and Services
We may from time to time use your personal health information to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.

Research
In limited circumstances, we may use and disclose your personal health information for research purposes. For example, a researcher may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not 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.

Confidentiality of Alcohol and Drug Abuse Patient Records
The confidentiality of alcohol and drug abuse patient records maintained by this facility is protected by federal law and regulations. Generally, the facility may not say to a person outside the program that you attend a drug or alcohol program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you consent in writing: (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law and regulations do not protect any information about a crime committed by you either at our facility or against any person who works for the facility or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Back to Top

Other Uses and Disclosures
We are permitted or required by law to make certain other uses and disclosures of your personal health information without your authorization. We may release your personal health information as follows:

For any purpose required by law; including suspected child abuse or neglect; or if we believe you to be a victim of abuse, neglect, or domestic violence; if required to do so by a court or administrative ordered subpoena or discovery request; if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings; as required by law to report wounds, injuries, and crimes;
For public health activities, such as required reporting of disease, injury, birth, death, and for required public health investigations; or if in limited instances if we suspect a serious threat to health or safety;
To the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
To your employer when we have provided health care to you at the request of your employer to determine workplacerelated illness or injury;
To coroners and/or funeral directors consistent with the law;
If necessary to arrange an organ or tissue donation from you to a transplant recipient for you;
If you are a member of the military as required by armed force services; we may also release your personal health information if necessary for national security or intelligence activities; and
To workers’ compensation agencies if necessary for your workers’ compensation benefit determination.

Ohio Law
Ohio law requires that we obtain an authorization from you in many instances before disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition; before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program; before disclosing information about mental health services you may have received; and before disclosing certain information to the State Long-Term Care Ombudsman.

Back to Top

RIGHTS THAT YOU HAVE

Access to Your Personal Health Information
You have the right to obtain a copy and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative and we may charge a reasonable fee.

Amendments to Your Personal Health Information.
You have the right to request in writing that personal health information we maintain about you be amended. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction requests.

Accounting for Disclosures of Your Personal Health Information.
You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. You may be charged a fee if you request more than one accounting within the same 12-month period.

Restrictions on Use and Disclosure of Your Personal Health Information
You have the right to request in writing restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request and we retain the right to terminate an agreedto restriction if we believe such termination is appropriate. You also have the right to terminate, in writing, any agreed-to restriction.

Back to Top

Complaints
If you believe your privacy rights have been violated, you may file a complaint to us in writing. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at Office for Civil Rights, U. S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601, in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Notice
You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.

FOR FURTHER INFORMATION AND REQUESTS
If you have questions or need further assistance regarding this Notice, or wish to exercise any of the rights stated in this Notice, you may contact the Privacy Officer of the Kettering Medical Center Network in writing at 3535 Southern Boulevard, Kettering, Ohio 45429 or by phone at 937-395-8581 or by e-mail at privacy.officer@kmcnetwork.org.

As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

EFFECTIVE DATE
This Notice of Privacy Practices is effective April 14, 2003.

Back to Top