NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.
The Student Medical Center is required by law to maintain
the privacy of your health information and to provide you
with notice of its legal duties and privacy practices with
respect to your health information. The Medical Center is
required to follow the privacy practices described in this
Notice.
We reserve the right to change our privacy practices and the
terms of this Notice at any time. If we change our notice,
we will post the revised notice in the facility and will
have them available upon request. You can receive a copy of
the current notice at any time. The effective date is listed
just below the title. You will be asked to acknowledge in
writing your receipt of this Notice.
You may view this Notice or any new notices on our website
at
www.shs.utoledo.edu.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The Medical Center is committed to maintaining the
confidentiality of your health information. Your health
information may be used and disclosed for purposes of
treatment, payment, and health care operations. Outside of
these permitted uses, we will not disclose your health
information without a signed authorization from you, unless
the law permits or requires us to use or disclose this
information without your authorization. You have the right
to revoke that authorization in writing except to the extent
any action has been taken in reliance on the authorization.
Treatment, Payment, and Health Care Operations. Except as
otherwise provided, the Medical Center may use and
disclosure your health information for purposes of
treatment, payment, and as otherwise necessary and permitted
by law, for our health care operations. This may include
disclosure to another health care provider, such as a
physician who is involved in your treatment, disclosure for
purposes of approval of reimbursement from your health plan,
or disclosure for audit purposes to our accountant.
Stricter Law. Certain provisions of Ohio law may be more
stringent than the federal laws and regulations protecting
the privacy of your medical information. The Student Medical
Center will, as required by law, comply with the more
stringent provisions of Ohio law.
Business Associates. It may be necessary for us to provide
your health information to certain outside persons or
entities that assist us with our health care operations,
such as auditing, accreditation, legal services, etc. These
business associates are required to properly safeguard the
privacy of your health information.
Appointments, Services, and Fundraising Efforts. We may
contact you to provide appointment reminders, information
about treatment alternatives, or other health-related
benefits and services that may be of interest to you. We may
contact you to support our fundraising efforts. You may
opt-out of receiving any further fundraising communications
from our facility by notifying the Student Medical Center
privacy officer in writing of your name, address, and
request to be removed from our fundraising mailing and
contact lists.
USE AND DISCLOSURES REQUIRING YOU TO HAVE AN OPPORTUNITY TO
OBJECT
Family and Friends. With your approval and using our
professional judgment, your health information may be
disclosed to family and friends who are directly involved in
your care or in the payment for your care.
If you are unavailable, incapacitated, or in an emergency
medical situation, and we determine that a limited
disclosure may be in your best interest, we may share
limited health information with such individuals without
your approval.
USES AND DISCLOSURES OF PHI
We may use or disclose medical information about you without
your prior authorization for several other reasons. Subject
to certain requirements, we may give out medical information
about you without prior authorization for public health
purposes, accrediting organizations such as AAAHC, required
abuse or neglect reporting, food and drug administration,
legal proceedings, law enforcement, research studies,
coroners, funeral directors, criminal activity, military
activity, worker’s compensation purposes, and emergencies.
We also disclose medical information when required by law,
such as in response to a request from law enforcement in
specific circumstances or in response to valid judicial or
administrative orders.
We may use or disclose your medical information for research
purposes but only with your prior authorization or a proper
waiver of authorization from the Internal Review Board or
Privacy Board.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
1.Restrictions on Use and Disclosure of Individual Health
Information. You have the right to request that we restrict
how we use and disclosure your health information. These
restrictions must be made in writing and signed by you or
your representative. The Student Medical Center is not
required to agree to your restrictions. We cannot agree to
limit uses/disclosures that are required by law. In the
event of a termination of an agreed-to restriction by us, we
will notify you of such termination. You may terminate, in
writing or orally, any agreed-to restriction by sending such
termination notice to the Student Medical Center Privacy
Officer.
2. Access and/or Copying Your Health Information. You have
the right to request to inspect and/or copy your health
information. Your request must be in writing on an access
form that you can obtain from the Student Medical Center.
You or your legal representative must sign the form and
return it to the front desk.
If you request copies, we may charge a fee for the cost of
copying, mailing or other related supplies access.
Depending on the circumstances, you may request a review of
the decision to deny access. If we deny your request, you
will be given written notice that will explain the basis of
the denial and your right to appeal.
3. Amendments to Individual Health Information. You have the
right to request that your health information be amended or
corrected. In certain cases, we may deny your request for
amendment. If so, you will be given written notice
explaining the basis and your right to appeal. You may also
submit a statement of disagreement to the denial. All
amendment requests must be in writing, signed by you or your
representative, and must state the reasons for the
amendment. If we make an amendment, we may notify others who
work with us and have copies of your record if we believe
that such notification is necessary. You may obtain a
Request for Amendment form from the front desk at the
Student Medical Center.
4. Accounting for Disclosures of Individual Health
Information. You have the right to receive an accounting of
certain disclosures of your health information made by us.
Requests must be made in writing and signed by you or your
representative. Request for accounting forms are available
from the Student Medical Center’s front desk. The first
accounting in any 12-month period is free.
5. Right to Paper Copy. If you are reading this on the
Internet or a posting, you have the right to receive a paper
copy of this or any revised Notice or an electronic copy by
e-mail upon request to the Student Medical Center Privacy
Officer.
6. Confidential Communications. You have the right to
request that medical information about you be communicated
to you in a confidential manner, such as sending mail to an
address other than your home, by notifying us in writing of
a specific way or location for us to use to communicate with
you.
How to Complain About Our Privacy Practices.
If you believe that we may have violated your privacy
rights, or you disagree with a decision we about access to
your PHI, you may file a complaint with the Privacy Officer
at the Student Medical Center, phone: (419) 530-3464. You
may also file a written complaint with the Secretary of the
U.S. Department of Health and Human Services at 200
Independence Avenue, SW, Washington D.C. 20201 or call
1-877-696-6775. There will be no retaliation for filing a
complaint.
This Notice describes how the Student Medical Center has
extended certain protections to your protected health
information (PHI) and how, when, and why we may use and
disclose your PHI. With certain exceptions, the Student
Medical Center will use or disclosure your PHI in the
minimum necessary manner to accomplish the intended purpose
of the use or disclosure. The Student Medical Center will
share PHI as is necessary to provide quality health care and
receive reimbursement for those services as permitted by
law.
If you have any questions about this Notice, please contact
the SMC privacy officer at 419-530-3464.
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