PATIENT RIGHTS & RESPONSIBILITIES

YOUR INDIVIDUAL RIGHTS

You have certain rights regarding your health information. These rights include:

• The right to restrict disclosure of Personal Health Information (related solely to those services provided by this healthcare provider) to a health plan if the service or healthcare item for which you, the patient, has paid out of pocket in full.
• The right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location to keep communications confidential;
• The right to obtain a paper copy of this Notice;
• The right to inspect and copy your health information (copies are available for a reasonable fee.) You must submit your request in writing and schedule an appointment to do this. However, our practice may deny your request in certain limited circumstances. Copies are available in electronic or paper format
• The right to request amendments to your health information you believe to be inaccurate. You must submit your request in writing to the Office Manager. You must provide us with a reason that supports your request. We may deny your request if you ask us to amend information that is in our opinion: a) accurate and complete; b) not part of the individually identifiable health information kept by or for our practice; c) not part of the individually identifiable health information which you would be permitted to inspect and copy; d) not created by our practice, unless the individual or entity that created it is not available to amend the information.
• The right to obtain an accounting of our uses and disclosures of your health information, subject to certain exceptions. You are required to submit your request in writing to the Office Manager. All requests for an “accounting of disclosures: must state a time period, which may not be longer than six (6) years from the date of the disclosure, and may not include dates prior to April 14, 2003.
• The right to request restrictions on our permitted uses and disclosures of your information. We are not, however, legally obligated to honor this request.
• The right to request communications regarding your health information be sent by alternative means or at an alternative location.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy of your information in accordance with this notice. We are required to notify you, the patient, of any breach of your unsecured personal health information. We are also required to provide you with this Notice, explaining our duties and practices regarding your health information. We are required to abide by the terms of this Notice.

We reserve the right to change the content of this Notice and to make new provisions regarding your protected health information. We will provide you a revised Notice during your visit after the revisions are effective. If you have any questions regarding this Notice, or wish to exercise any of your rights as described herein, you may contact the Administrator at (419) 353-7069. Any complaint regarding your rights or our practices, can be directed the Privacy Officer by e-mail at PrivacyOfficer@woodcountyhospital.org, or in writing at 950 W. Wooster Street, Bowling Green, OH, 43402. Finally, you may submit a complaint to the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.