Patient Guide - Patient Rights, Responsibilities, and Privacy

You have the right to considerate, respectful, and responsive care. You have the right to medical treatment regardless of your age, race, color, national origin, religion, language, sex, gender identity or expression, sexual orientation, disability, socioeconomic status, or sources of payment for care.
You have the right to receive the visitors whom you designate (or your support person designates, as appropriate) including, but not limited to, a spouse, a domestic partner, another family member, or a friend. You may also deny or withdraw consent of a visitor or visitors at any time. Premier Health hospitals do not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Please note that Premier Health hospitals may limit visitors at times for clinical and safety reasons as appropriate.
You have the right to respectful consideration of your psychosocial, spiritual, and cultural values, needs, and preferences. You have the right to request and receive pastoral/spiritual care services.
You have the right to prepare a living will and/or appoint a surrogate to make decisions on your behalf in accordance with Ohio law. You have the right to present your advance directive (living will and/or health care power-of-attorney) at the time of admission and have hospital staff and practitioners comply with your directive to the extent permitted by law and hospital policy. Premier Health is opposed to and will not participate in assisted suicide and/or active euthanasia, nor will life-sustaining treatment be withheld or withdrawn in the presence of a viable fetus. Should you want to formulate your wishes through an advance directive during or after admission, you have the right to do so. To arrange for this, speak to your nurse or call the patient experience department (see phone numbers below).
You have the right to have your physician promptly notified of your admission to the hospital.
You have the right to have a family member or representative of your choice notified of your admission to the hospital upon request.
You have the right as a competent adult to be involved in all aspects of your care. If you are unable to make decisions for yourself, we will involve your surrogate decision maker, next-of-kin, or a family member as appropriate and allowed by law.
You have the right to and are encouraged to obtain timely, relevant, current, and understandable information concerning your diagnosis, treatment, and prognosis from your physicians and other direct caregivers.
You have the right to be informed about any proposed treatment options so that you understand the potential risks, benefits, and possible side effects of those options, the likelihood of achieving your goals, problems that might occur during recuperation, and alternative courses of treatment and their associated risks, benefits, and side effects as well as the risks of not receiving treatment before making decisions about your medical care.
You have the right to be informed about the outcomes of care, treatment, and services, including unanticipated outcomes, that you need to know about in order to participate in current and future health care decisions.
You have the right to appropriate assessment and management of your pain consistent with accepted medical standards.
You have the right to know the name of the physician who has primary responsibility for your care as well as the names of other professionals responsible for authorizing and performing treatments.
You have the right to refuse treatment to the extent permitted by law and to be informed of the consequences of your refusal. This refusal includes, but is not limited to, experimental research.
You have the right to a reasonable response to your requests for hospital services within the available resources of the hospital based upon priority of need and continuity of care. This includes discharge planning services such as facilitating transfers to another medical or extended care facility.
You have the right to reasonable resources to facilitate effective communications, e.g., language interpreter, sign language interpreter, and devices to assist the hearing impaired.
You and/or your next-of-kin, or an appointed surrogate speaking on your behalf, have the right to request and participate in appropriate discussion of ethical concerns and issues related to your care. To arrange such discussion, speak with the nursing personnel caring for you or your loved one or call the patient experience department (see phone numbers below).
You have the right to confidentiality in regard to your medical record and care.
You have the right to personal privacy and safety including access to protective services should they be required, e.g., guardianship and advocacy services. You have the right to receive care in a safe setting free from all forms of abuse, harassment, neglect, or exploitation.
You have the right to be free from any form of restraint and/or seclusion that is not medically or behaviorally necessary. Restraint and/or seclusion may not be used as a means of discipline, coercion, convenience, or retaliation.
You have the right to know the rules that apply to your conduct and that of your family and visitors while you are a patient at any Premier Health hospital.
You have the right to access, request amendment to, and obtain information on disclosures of your health information in accordance with hospital policy and as allowed by law and regulation.
You have the right to receive upon request a detailed explanation of your charges and bills for medical services and treatment. You have the right to ask and be informed about the existence of business relationships among hospitals, educational institutions, and other health care providers or payers that may influence your care.
You have the right to receive a copy of the hospital’s nursing staffing plan on request.
You have the right to express concerns about your care at any Premier Health hospital. Speak to your physician or the staff caring for you if you have any concerns about your care. If the issue is not resolved to your satisfaction, contact the patient experience department (see phone numbers below) to speak to a patient experience representative. Your concerns will be heard, investigated, and responded to in a timely manner.

Patient Experience Department Phone Numbers

Atrium Medical Center: (513) 974-5072(513) 974-5072
Miami Valley Hospital: (937) 208-2666(937) 208-2666
Miami Valley Hospital North: (937) 208-2666(937) 208-2666
Miami Valley Hospital South: (937) 208-2666(937) 208-2666
Upper Valley Medical Center: (937) 440-4717(937) 440-4717

You also have the right to file a complaint with The Joint Commission which accredits all Premier Health hospitals or the Ohio Department of Health, regardless of whether you choose to first use the Premier Health hospital complaint process. Complaints may be forwarded to The Joint Commission by using either of the options below:

At www.jointcommission.org, using the “Report a Safety Concern” link in the “Connect with Us” section on the home page of the website
By mail to The Office of Quality and Patient Safety, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181
More information on how to file a complaint is available by clicking on the “Report a Safety Concern” link noted above or by calling The Joint Commission's patient safety event phone line at (800) 994-6610 (800) 994-6610

Complaints may be forwarded to the Ohio Department of Health as follows:

Online: At https://complainttracking.odh.ohio.gov/ publiccomplaint/publiccomplaintform, complete and submit the on-line complaint form
Email: HCComplaints@odh.ohio.gov
Phone: (800) 342-0553(800) 342-0553

Patient Responsibilities

You have the responsibility to make informed decisions about your health care. This includes seeking and considering the information provided by your physician and other caregivers.
You have the responsibility to provide accurate and complete information about all matters relating to your health.
You have the responsibility to inform the hospital staff and your health care providers about the existence of any living will and/or health care power-of-attorney that you have prepared and to present these documents so that they are readily available and can be included in your medical record.
You have the responsibility to report any changes in your condition to your physician and/or the nurse caring for you.
You have the responsibility to follow treatment plans and instructions recommended by your physician. This includes your responsibility to ask questions when you do not understand the plan of care or instructions given to you. If you choose not to follow instructions, you are responsible for the outcome.
You have the responsibility to cooperate with the hospital staff caring for you and to ask questions when you do not understand instructions, need clarification, or have concerns about your plan of care.
You have the responsibility to express any concerns that you have about your hospital care. Speak to your physician, the staff caring for you, or call the patient experience department (see phone numbers above) to express and discuss concerns about your care.
You have the responsibility to abide by the rules that apply to your conduct and that of your family and visitors while you are a patient at any Premier Health hospital. You also have the responsibility to be considerate of the hospital’s staff and property, as well as other patients and their property, privacy, and confidentiality.
You have the responsibility to ensure payment of your bill(s) for care and treatment received. This includes the responsibility to cooperate with appropriate hospital staff to provide accurate information for processing insurance forms and other payment processes.
You have the responsibility to send valuables home with your family/friends or to secure them in the hospital safe by notifying your nurse while you are a patient at any Premier Health hospital.

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Premier Physician Network (PPN) wants you to be aware of your privacy, rights and responsibilities as a patient.

You Have the Right:

Not to be denied participation in treatment services based on race, color, creed, sex, sexual orientation, national origin, handicap, religion or age.
To reasonably expect, from staff members responsible for your care and welfare, complete and current information concerning your condition.
To know by name and specialty, if any, the staff members responsible for your care.
To reasonable consideration of your privacy and individuality, and to be treated with respect and full recognition of your dignity, individually and reasonable cultural needs.
To respectfulness and privacy as it relates to your treatment program.
To expect reasonable safety related to the facility’s practices and environment.
To expect reasonable continuity of care, which includes when services and staff are available.
To be reasonably informed, before or during your visit, of services available and/or related charges.
To be given the opportunity to participate in planning your treatment program.
To confidentiality.
To request a consultation or second opinion at your expense.
To have your rights explained to you in a language you understand.
To have an advance directive (living will, health care proxy or durable power of attorney for health care).

You Have the Responsibility:

To be honest about matters that relate to you as a patient.
To attempt to understand your medical condition/s and ask for help when you do not.
To know the staff who are caring for you.
To report changes in your condition to those responsible for your care and welfare.
To be considerate and respectful of the rights of fellow patients and staff.
To honor the confidentiality and privacy of other patients.
To notify the administrator/manager of this center if you feel your rights are being violated.
To assure that the financial obligations of your health care are fulfilled as promptly as possible.
To follow this facility’s rules and regulations affecting your care and conduct.

For any concerns about your care, please contact the office manager of the Premier Physician Network practice where you received care.

Potential Conflicts of Rights

In disputes regarding the rights or treatment of a neonate, child or adolescent patient and the rights of their parents and/or guardians, the facility shall consult with the appropriate County Child Protective Service Agency to ensure that the minor’s rights are protected.

Your Bill of Rights

As a patient of Fidelity Health Care you have rights which include, but are not limited to, the following. You have the right to:

Be given information about your rights for receiving home care services, in a language you can understand, including translation services at no cost. Please contact Fidelity Health Care if these services are needed.
Be given quality home care services without discrimination for your race, color, creed, religion, sex, national origin, sexual preference, handicap, or age.
Be treated with courtesy and respect by all who provide home care services to you.
Have your property treated with courtesy and respect by all who provide home care services to you.
Be free from verbal, mental, sexual, and physical abuse, including injuries for which a cause is not known, neglect and misuse or theft of property.
Be advised of any cost to you, known to the agency, before services are provided and in advance of reducing or discontinuing ongoing care.
Participate in, be informed about, and agree to or refuse care before and during treatment, where appropriate.
Have an advance directive for medical care, such as a living will or a person you choose to make decisions for you, respected to the extent provided by the law.
Be included in any conversations about ethical issues that arise in your care.
Have a confidential clinical record and the ability to request a copy of the record.
Receive all services included in the plan of care.
Be given information about any possible transfer of your home care to another health care facility and/or the end of home care service to you.
Speak out about complaints with and/or suggest changes in home care services and/or staff without any discrimination or retaliation.
Contact Fidelity Health Care with any suggestions or complaints. The number is (937) 208-6400(937) 208-6400 or (800) 946-6344(800) 946-6344.
To make complaints to the agency about treatment or care that was (or was not) provided, and the lack of respect for property and/or person by anyone who is providing care. If you wish to make a complaint, please call the Fidelity Health Care at (937) 208-6400(937) 208-6400 or (800) 946-6344(800) 946-6344.
If a complaint cannot be resolved to your satisfaction, a state toll-free hot line number is available to receive complaints. The number is (800) 342-0553(800) 342-0553. This line is available weekdays, 8 a.m. – 5 p.m. EST.

Your Responsibilities

Fidelity Health Care and our personnel have the right to expect reasonable behavior, which takes into consideration the nature of your illness or home situation. You have the responsibility to:

Remain under a physician’s care.
Give accurate and complete health information concerning your past illnesses, hospitalizations, medications, allergies and other pertinent issues.
Assist in developing and maintaining a safe environment.
Show our staff respect, courtesy and consideration.
Participate in the development and update of your home care plan of treatment, in order to learn how to manage your care, and to identify a caregiver.
Follow your home care plan of care and carry out mutually agreed upon responsibilities.
Request further information about anything you do not understand.
Contact your clinician or doctor whenever you notice any change in your condition.
Contact us if you have a problem with care or equipment.
Notify us if your medications change.
Inform us when you will not be home for a visit.
Notify us of any change of address.
Contact us if you are hospitalized.
Contact us if you have an infectious disease during the time you are receiving services from Fidelity Health Care, except where exempted by law.
Notify us if you receive additional services from another company or rehabilitation department.
Notify us if there are any changes to your advance directives.
Contact Fidelity Health Care whenever your insurance company or plan changes.
Promptly meet your financial responsibility.

Discharge and Transfer

Fidelity Health Care may only discharge or transfer you from home care services when certain situations occur.

You have met the treatment goals established by us, you, your caregivers, and physician to a level where services are no longer necessary.
Your physician stops services or will no longer sign orders.
You or your legal representative requests an end to our services.
Your medical insurance or you will no longer pay for services.
Your home environment does not provide an appropriate and safe setting for care or lessens our ability to provide effective care after attempts have been made to adjust the environment/situation.
There has been a major change in your condition, your home situation or caregiver support so that we can no longer safely and reasonably meet your home care needs.
You pass away or;
Fidelity Health Care stops operations.
Fidelity Health Care will arrange a safe and appropriate transfer to another care setting if necessary and/or provide you and your caregivers contact information for other providers.

This notice describes how your protected health information may be used and disclosed and how you can get access to this information. Please review it carefully.

The terms of this Notice of Privacy Practices apply to Premier Health operating as a clinically integrated health care arrangement composed of Miami Valley Hospital, Atrium Medical Center, and Upper Valley Medical Center, as well as outpatient sites, physicians, and other licensed professionals seeing and treating patients at these sites. A complete listing of our service locations is available upon request. The members of this clinically integrated health care arrangement will share protected health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected 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 this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. You may receive a copy of any revised notices at the Registration Desk.

Uses and Disclosures of Your Protected Health Information

Your Authorization: Except as outlined below, we will not use or disclose your protected health information 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. There are certain uses and disclosures of your protected health information for which we will always obtain a prior authorization, and these include:

Marketing communications, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health or wellness information, or a communication about health related products or services that we offer or that are directly related to your treatment;
Most sales of your protected health information unless for treatment or payment purposes or as required by law; and
Psychotherapy notes unless otherwise permitted or required by law.

Uses and Disclosures for Treatment: We will use and disclose your protected 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 protected 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 hospital, you are going to receive home health care, we may release your protected 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 use and disclose your protected health information as necessary for the payment 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 a 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 payment of your bill.

Uses And Disclosures For Health Care Operations: We will use and disclose your protected 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 protected health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your protected 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.

Health Information Exchange: We may participate in health information exchanges (HIEs) to facilitate the secure exchange of your electronic health information between and among other health care providers, health plans, and health care clearinghouses that participate in the HIE. In order to provide better treatment and coordination of your health care, we may share and receive your health information for treatment, payment, or other health care operations. Your participation in the HIE is voluntary, and your ability to obtain treatment will not be affected if you choose not to participate. You may opt out at any time by notifying the Health Information Management/Medical Records Department. However, your choice to opt-out does not affect health information that was disclosed through an HIE prior to the time that you opted out.

Our Facility Directory: We maintain a facility directory listing the name, room, and general condition of our patients. Unless you choose to have your information excluded from this directory, your information will be disclosed to anyone who requests it by asking for you by name. You have the right during registration, or at any time during your hospitalization, to request that your information be excluded from this directory and also to restrict what information is provided and/or to whom.

Family And Friends Involved In Your Care: With your approval, from time to time we may disclose your protected health information to designated family, friends, and others who are involved in your care, or are involved in payment for your care, in order to facilitate that person’s involvement in caring for you or in 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 protected health information with such individuals without your approval. We may also disclose limited protected 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.

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 protected 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 on our behalf. You have the right to opt out of receiving fundraising materials/communications and may do so by calling, emailing, or writing the appropriate Foundation and identifying yourself and stating that you do not wish to receive future fundraising requests:

Atrium Medical Center Foundation, One Medical Center Drive, Middletown, OH 45005, (513) 974-5144(513) 574-5144 or toll free (800) 338-4057(800) 338-4057, ext. 5144, foundation@AtriumMedCenter.org
Miami Valley Hospital Foundation, One Wyoming St., Dayton, OH 45409, (937) 208-2700(937) 208-2700, mvhf@mvh.org
Upper Valley Medical Center Foundation, , 3130 N. County Road 25-A, Troy, OH 45373, (937) 440-7541(937) 440-7541, UVMCFoundation@uvmc.com

We will honor your request after the date we receive your direction.

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, to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you would prefer that appointment reminders not be left on voice mail or sent to a particular address, we will accommodate all reasonable requests. You may request such confidential communication in writing by sending your request to the outpatient center where you receive care.

Health Products And Services: We may use your protected health information from time to time 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 protected health information for research purposes. For example, a research organization 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 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 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.

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

For any purposes required by law;
For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
As required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
To a student’s school, but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
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 workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
If required to do so by subpoena or discovery request; in most cases you will have notice of such release;
To law enforcement officials as required by law to report wounds, injuries, and crimes;
To coroners and/or funeral directors consistent with law;
If necessary to arrange for an organ or tissue donation from you or a transplant for you;
If, in limited instances, we suspect a serious threat to health and safety;
As required by armed forces services if you are a member of the military; we may also release your protected 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 requires that we obtain a consent 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, and before disclosing information about mental health services you may have received. For full information on when such consents may be necessary, you can contact the Privacy Officer, 110 N. Main St., Suite 930, Dayton, OH 45402.

Rights That You Have

Access To Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you per page if you request a copy of the information. We will also charge for the postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an Authorization for Release of Medical Information/Patient Access Form from the Health Information Management/ Medical Records Department.

You have the right to obtain an electronic copy of your health information that exists in an electronic format, and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information. We will charge you a fee for our labor and supplies in preparing your copy of the electronic health information.

Amendments To Your Protected Health Information: You have the right to request in writing that protected health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. In order to be considered by us, all amendment requests must be submitted using an Amendment Request Form signed by you or your representative. This form is available from the Health Information Management/ Medical Records Department. If any amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.

Accounting Of Disclosures Of Your Protected Health Information: You have the right to receive an accounting of certain disclosures by us of your protected health information for six years prior to the date of your request. Requests must be made in writing and signed by you or your representative. Submit your request to the Health Information Management/Medical Records Department. The first accounting in any 12-month period is free. You will be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions On Use And Disclosure Of Your Protected Health Information: You have the right to request, in writing, restrictions on certain of our uses and disclosures of your protected health information for treatment, payment, or health care operations. Please send your restrictions request to the Health Information Management/Medical Records Department. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing, any agreed-to restriction by sending such notice to one of the following:

Atrium Medical Center
Health Information Management/Medical Records Department
Atrium Medical Center
One Medical Center Drive
Middletown, OH 45005

Miami Valley Hospital
Health Information Management Services
Miami Valley Hospital
One Wyoming St.
Dayton, OH 45409

Upper Valley Medical Center
Health Information Services/Medical Records Department
Upper Valley Medical Center, 3130 N. County Road 25-A
Troy, OH 45373

We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care item or service for which Atrium Medical Center, Miami Valley Hospital, or Upper Valley Medical Center respectively has been paid in full.

Breach Notification: In the unlikely event that there is a breach or unauthorized release of your protected health information, you will receive notice and information on steps you may take to protect yourself from harm.

Complaints: If you believe your privacy rights have been violated, you can file a complaint, in writing, with the Privacy Officer, Premier Health, 110 N. Main St., Suite 930, Dayton, OH 45402. You may also file a complaint, in writing, within 180 days of a violation of your rights with the Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601. There will be no retaliation for filing a complaint.

For Further Information

If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, 110 N. Main St., Suite 930, Dayton, OH 45402.

You may also reach us by contacting the Premier Health Corporate Offices online.

As a patient, you have 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 September 1, 2013.

The terms of this Notice of Privacy Practices apply to Premier Physician Network (PPN) operating as a clinically integrated health care network composed of Physicians and Advanced Practice Providers (APP’s), specialty and primary care practices, and other licensed professionals seeing and treating patients at these sites. A complete listing of our service locations is available upon request. The members of this clinically integrated health care network will share protected health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected 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 this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. You may receive a copy of any revised notices at the Registration Desk.

Uses and Disclosures of Your Protected Health Information

Your Authorization: Except as outlined below, we will not use or disclose your protected 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. There are certain uses and disclosures of your protected health information for which we will always obtain a prior authorization, and these include:

Marketing communications, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health wellness information, or a communication about health related products or services that we offer or that are directly related to your treatment;
Most sales of your protected health information unless for treatment or payment purposes or as required by law; and
Psychotherapy notes unless otherwise permitted or required by law.

Uses and Disclosures for Treatment: We will use and disclose your protected 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 protected 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 office, you are going to the hospital, we may release your protected 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 use and disclose your protected health information as necessary for the payment 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 a 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 payment of your bill.

Uses and Disclosures for Health Care Operations: We will use and disclose your protected health information as necessary, and as permitted by law, for our healthcare operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your protected 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.

Health Information Exchange: We may participate in health information exchanges (HIEs) to facilitate the secure exchange of your electronic health information between and among other health care providers, health plans, and health care clearinghouses that participate in the HIE. In order to provide better treatment and coordination of your health care, we may share and receive your health information for treatment, payment, or other health care operations. Your participation in the HIE is voluntary, and your ability to obtain treatment will not be affected if you choose not to participate. You may opt-out at any time by notifying the Health Information Management/Medical Records Department. However, your choice to opt-out does not affect health information that was disclosed through an HIE prior to the time that you opted out.

Family and Friends Involved in Your Care: With your approval, from time to time we may disclose your protected health information to designated family, friends, and others who are involved in your care, or are involved in payment for your care, in order to facilitate that person’s involvement in caring for you or in 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 protected health information with such individuals without your approval. We may also disclose limited protected 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.

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 protected 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.

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, to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you would prefer that appointment reminders not be left on voice mail orsent to a particular address, we will accommodate all reasonable requests. You may request such confidential communication in writing by sending your request to the physician practice where you receive care.

Health Products and Services: We may use your protected health information from time to time 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 protected health information for research purposes. For example, a research organization 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 which oversees the research or by representations of the researchers that limit their use and disclosure of patient information. This notice describes how your protected health information may be used and disclosed and how you can get access to this information. Please read it carefully.

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 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.

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

For any purposes required by law;
For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
As required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
To a student’s school, but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
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 workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
If required to do so by subpoena or discovery request; in most cases you will have notice of such release;
To law enforcement officials as required by law to report wounds, injuries, and crimes;
To coroners and/or funeral directors consistent with law;
If necessary to arrange for an organ or tissue donation from you or a transplant for you;
If, in limited instances, we suspect a serious threat to health and safety;
As required by armed forces services if you are a member of the military; we may also release your protected 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 requires that we obtain a consent 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, and before disclosing information about mental health services you may have received. For full information on when such consents may be necessary, you can contact the Privacy Office, 110 N. Main Street, Suite 930, Dayton, Ohio 45402.

Rights That You Have

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you per page if you request a copy of the information. We will also charge for the postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an Authorization for Release of Medical Information/Patient Access Form from the physician practice. You have the right to obtain an electronic copy of your health information that exists in an electronic format, and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information. We will charge you a fee for our labor and supplies in preparing your copy of the electronic health information.

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. In order to be considered by us, all amendment requests must be submitted using an Amendment Request Form signed by you or your representative. This form is available from your physician practice. If any amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.

Accounting of Disclosures of Your Protected Health Information:

You have the right to receive an accounting of certain disclosures by us of your protected health information for six years prior to the date of your request. Requests must be made in writing and signed by you or your representative. Submit your request to your physician practice. The first accounting in any 12-month period is free. You will be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Protected Health

Information: You have the right to request, in writing, restrictions on certain of our uses and disclosures of your protected health information for treatment, payment, or health care operations. Please send your restrictions request to your physician practice. We

are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing, any agreed-to restriction by sending such notice to your physician practice. We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care item or service for which the practice has been paid in full.

Breach Notification: In the unlikely event that there is a breach or unauthorized release of your protected health information, you will receive notice and information on steps you may take to protect yourself from harm.

Complaints: If you believe your privacy rights have been violated, you can file a complaint, in writing, with the Privacy Office, Premier Health, 110 N. Main Street, Suite 930, Dayton, Ohio 45402. You may also file a complaint, in writing, within 180 days of a violation of your rights with the Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601. There will be no retaliation for filing a complaint.

For Further Information

If you have questions or need further assistance regarding this Notice, you may contact the Privacy Office at 110 N. Main Street, Suite 930, Dayton, Ohio 45402 or PPNPrivacyOffice@premierhealth.com.

As a patient, you have 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 January 1, 2019

This Notice describes how your protected health information may be used and disclosed and how you can get access to this information. Please review it carefully.

Fidelity Health Care is required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected 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 this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. You may receive a copy of any revised

notices by contacting the Fidelity Health Care Privacy Officer.

Uses and Disclosures of Your Protected Health Information Your Authorization

Except as outlined below, we will not use or disclose your protected 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. There are certain uses and disclosures of your protected health information for which we will always obtain a prior authorization, and these include:

Marketing communications, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health or wellness information, or a communication about health related products or services that we offer or that are directly related to your treatment;
Most sales of your protected health information unless for treatment or payment purposes or as required by law; and
Psychotherapy notes unless otherwise permitted or required by law.

Uses and Disclosures for Treatment: We will use and disclose your protected health information as necessary for your treatment. For instance, we may use your health information to coordinate care within Fidelity and with others involved in your care, such as your attending physician and other health care professionals. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. We may also disclose your health information to individuals outside of Fidelity involved in your care, including family members, pharmacists, and suppliers of medical equipment.

Uses and Disclosures for Payment: We will use and disclose your protected health information as necessary for payment purposes. For instance, we may include your health information in invoices to collect payment from third parties for the care you receive from Fidelity. For example, we may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Fidelity. We also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for home care and the services that will be provided to you.

Uses and Disclosures for Health Care Operations: We will use and disclose your protected health information as necessary, and as permitted by law, for our healthcare operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your protected 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.

Health Information Exchange: We may participate in health information exchanges (HIEs) to facilitate the secure exchange of your electronic health information between and among other health care providers, health plans, and health care clearinghouses that participate in the HIE. In order to provide better treatment and coordination of your health care, we may share and receive your health information for treatment, payment, or other health care operations. Your participation in the HIE is voluntary, and your ability to obtain treatment will not be affected if you choose not to participate. You may opt-out at any time by notifying the Fidelity Privacy Officer. However, your choice to opt-out does not affect health information that was disclosed through an HIE prior to the time that you opted out.

Family and Friends Involved in Your Care: With your approval, from time to time we may disclose your protected health information to designated family, friends, and others who are involved in your care, or are involved in payment for your care, in order to facilitate that person’s involvement in caring for you or in 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 protected health information with such individuals without your approval. We may also disclose limited protected 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.

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 protected 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 on our behalf. You have the right to “opt-out” of receiving fundraising materials/communications and may do so by calling the Fidelity Privacy Officer at (937) 208-6400 or (800) 946-6344 or by writing to

the Privacy Officer at 3170 Kettering Blvd., Moraine, OH 45439 identifying yourself and stating that you do not wish to receive future fundraising requests. We will honor your request after the date we receive your direction.

Appointments and Services: We may contact you to provide a reminder that you have an appointment for a home visit or are eligible to purchase new supplies. You have the right to request, and we will accommodate reasonable requests, to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you would prefer that appointment reminders not be left on voice mail or sent to a particular address, we will accommodate all reasonable requests. You may request such confidential communication in writing by sending your request to the Fidelity Health Care Privacy Officer.

Health Products and Services: We may use your protected health information from time to time 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 protected health information for research purposes. For example, a research organization 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 which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.

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

For any purposes required by law;
For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
As required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
To a student’s school, but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
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 workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
If required to do so by subpoena or discovery request; in most cases you will have notice of such release;
To law enforcement officials as required by law to report wounds, injuries, and crimes;
To coroners and/or funeral directors consistent with law;
If necessary to arrange for an organ or tissue donation from you or a transplant for you;
If, in limited instances, we suspect a serious threat to health and safety;
As required by armed forces services if you are a member of the military; we may also release your protected 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 requires that we obtain a consent 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, and before disclosing information about mental health services you may have received. For full information on when such consents may be necessary, you can contact the Privacy Officer, 3170 Kettering Blvd., Moraine, OH 45439.

Rights That You Have

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. Your record will be made available to you, free of charge, on your nest home visit or within 4 business days (whichever comes first). A request to inspect and/or copy records containing your protected health information may be submitted in writing to the Fidelity Privacy Officer. You have the right to obtain an electronic copy of your health information that exists in an electronic format, and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information.

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. In order to be considered by us, all amendment requests must be submitted in writing to the Fidelity Health Care Privacy Officer. Fidelity may deny the request if it is not in writing or does not include a reason for the amendment. If any amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.

Accounting of Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures by us of your protected health information for six years prior to the date of your request. Requests must be made in writing and signed by you or your representative. Submit your request to the Fidelity Health Care Privacy Officer. The first accounting in any 12-month period is free. You will be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Protected Health

Information: You have the right to request, in writing, restrictions on certain of our uses and disclosures of your protected health information for treatment, payment, or health care operations. Please send your restrictions request to the Fidelity Health Care Privacy officer. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing, any agreed-to restriction by sending such notice to the Fidelity Privacy Officer, 3170 Kettering Blvd., Moraine, OH 45439. We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care item or service for which Fidelity Health Care has been paid in full.

Breach Notification: In the unlikely event that there is a breach or unauthorized release of your protected health information, you will receive notice and information on steps you may take to protect yourself from harm.

Contact Person: Fidelity Health Care has designated a Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 3170 Kettering Blvd., Moraine, OH 45439, (937) 208-6400, or (800) 946-6344.

Complaints: If you believe your privacy rights have been violated, you can file a complaint, in writing, with the Fidelity Health Care Privacy Officer. You may also file a complaint, in writing, within 180 days of a violation of your rights with the Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601. 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

If you have questions or need further assistance regarding this Notice, you may contact the Fidelity Health Care Privacy Officer. As a patient, you have 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 September 23, 2013.