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Avita Health System and all associates at all locations are required by law to maintain the privacy of patientsa Protected Health Information (PHI) and to provide individuals with the following Notice of the legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and these new terms will affect all PHI that we maintain at that time.

In certain circumstances we may use and disclose PHI about you without your written consent:

For Treatment : We will use health information about you to provide you with medical treatment or services. We will disclose PHI about you to doctors, nurses, technicians, students in health care training programs, or other personnel 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 might 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 departments of Avita may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information about you to people outside Avita who provide your medical care like nursing homes or other doctors.

For Payment : We will use and disclose information to other health care providers to assist in the payment of your bills.A We will use it to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment.

For Health Care Operations : We may use and disclose PHI about you for the purpose of our business operations. These business uses and disclosures are necessary to make sure that our patients receive quality care and cost effective services. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of our staff, contracted employees and students in caring for you.

Business Associates: We may use or disclose your PHI to an outside company that assists us in operating our health system.A They perform various services for us. This includes, but is not limited to, auditing, accreditation, legal services, and consulting services. These outside companies are called "business associates" and they contract with us to keep any PHI received from us confidential in the same way we do.A

Family Members and Friends : We may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances.A But you also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care.

Appointments : We may use and disclose PHI to contact you for appointment reminders and to communicate necessary information about your appointment.

Hospital Directory : When you are an inpatient admitted to the hospital, Avita hospitals may list certain information about you, such as your name, your location in the hospital, and your religious affiliation, in a hospital directory. The hospitals can disclose this information, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to members of the clergy even if they do not ask for you by name. You may request that no information contained in the directory be disclosed. To restrict use of information listed in the directory, please inform the admitting staff or your nurse. They will assist you in this request. In emergency circumstances, if you are unable to communicate your preference, you will be listed in the directory.

Fundraising Activities : We may use PHI, such as your name, address, phone number and the dates you received services, to contact you to raise money for Avita interests. We may share this information with a foundation associated with Avita Health System to work on our behalf. If you do not want Avita affiliates to contact you for our fundraising, you must notify us in writing. Please contact the Privacy Officer or designee to help you with this request.

Future Communications : We may use your name, address, and phone number to contact you to provide you with general information about new programs or other services we offer, or the Avita Health System newsletters. An example of this would be mailers to all patients regarding a walk or run for breast cancer. This same information may be used to develop new programs as part of promoting health.

Public Health and Government Functions : We will disclose your PHI in certain circumstances to control or prevent a communicable disease, injury or disability; to report births and deaths; and for public health oversight activities or interventions.A We may disclose your PHI to the Food and Drug Administration (FDA) to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law or to a state or federal government agency to facilitate their functions.

Required or Permitted by Law: We will disclose your PHI when required to do so by federal, state, or local law. We are permitted, and required in some cases, to release your PHI in certain circumstances to report suspected elder or child abuse to law enforcement or other governmental agencies responsible to investigate or prosecute abuse or to respond to a valid court order. These disclosures may go to the Department of Health Services (DHS), the Department of Children and Families (DCF), a protection or advocacy agency, law enforcement authorities investigating abuse, neglect, physical injury, death, and suspicious wounds, burns, or gunshot wounds, your court appointed guardian or agent you have appointed under a health care power of attorney, a prisoner's health care provider, a medical examiner, coroner, and funeral director regarding a death, law enforcement officials with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons.

Organ, Eye and Tissue Donation : We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.

Research : Avita may use and share your health information for certain kinds of research.

Workers' Compensation : We will disclose your health information that is reasonably related to a worker's compensation illness or injury following written request by your employer, worker's compensation insurer, or their representative.

Employer Sponsored Health and Wellness Services : We maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site. We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care.

Shared Medical Record/Health Information Exchanges : We maintain PHI about our patients in shared electronic medical records that allow the Avita associates to share PHI. We may also participate in various electronic health information exchanges that facilitate access to PHI by other health care providers who provide you care. For example, if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you.

Your Rights Regarding Your PHI:
The Right to Access to Your Own Health Information: You have the right to inspect and copy most of your protected health information for as long as we maintain it as required by law. All requests for access mu
st be made in writing. We may charge you a nominal fee for each page copied and postage if applicable. You also have the right to ask for a summary of this information. If you request a summary, we may charge you a nominal fee. Please contact the Avita Health Information/Medical Records Department with any questions or requests.

Right to Request Restrictions : You have the right to request certain restrictions of our use or disclosure of PHI for treatment, payment or health care operations. We are not required to agree to your request in most cases. But if the Avita Health System agrees to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment. One example would be if a patient pays for a service completely out of pocket and asks Avita not to tell his/her insurance company about it and Avita agrees to that restriction, we will abide by it. A request for restriction should be made in writing. To request a restriction you must contact Health Information/Medical Records Department. We reserve the right to terminate any previously agreed-to restrictions.

Right to Inspect and Copy : You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to your nurse or doctor while you are an inpatient or to the Health Information/ Medical Records Department while an outpatient. For copies of your PHI, requests must go to the Health Information/ Medical Records Department. There may be a charge for these copies.

Right to Amend : If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as Avita maintains the information. Requests for amending your PHI should be made to the Health Information/Medical Records Department. The Avita personnel who maintain the information will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to an Accounting: With some exceptions, you have the right to receive an accounting of certain disclosures of your PHI.A A nominal fee will be charged for the record search .

Complaints: You may submit any complaints to the Avita Health System Privacy Officer.A You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services if you feel that your rights have been violated. There will be no retaliation from Avita for making a complaint.

July 2011

PLEASE NOTE: The internet is an unregulated source of information. No controls or restrictions are enforced and the quality of the data varies widely. As such, Bucyrus Community Hospital, its staff, and medical personnel assume NO LIABILITY for the information presented, including all links to other sites which may or may not contain copyrighted material. The information on this website is not to be considered medical advice and you would consult your physician on specific medical questions.

629 Sandusky Avenue, Bucyrus, Ohio 44820 | 419-562-4677 | (c)2011 Copyright Avita Health Systems | All Rights Reserved