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Barnesville, OH 43713  
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BARNESVILLE HOSPITAL
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO YOUR MEDICAL INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice also describes how you can:
  • Amend your medical information
  • Receive an accounting of disclosure of your medical information
  • Request restrictions on the use and disclosure of your medical information
  • File a complaint if you feel that your privacy rights have been violated
This notice was developed in accordance with the requirements of 45 CFR Part 164.520 of the Federal Register.

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 this 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 the Registration Desk or a copy may be obtained by mailing a request to:

  Attention: Privacy Officer
Barnesville Hospital Association
P.O. Box 309
639 West Main Street
Barnesville, OH 43713-0309



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, tests, 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
      • For instance, 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
  • 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 and legal 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 individuals 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 individuals 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
  • 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 aspects 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, together with a statement that you do not wish to receive fundraising materials or communications from us, to:
      Attention: Privacy Officer
      Barnesville Hospital Association
      P.O. Box 309
      639 West Main Street
      Barnesville, OH 43713-0309
  • 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
      • For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communication in writing and may send your request to:
        Attention: Privacy Officer
        Barnesville Hospital Association
        P.O. Box 309
        639 West Main Street
        Barnesville, OH 43713-0309
  • 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 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 has not been 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
  • 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 consent or authorization. Federal laws and regulations do not protect any information about suspected abuse or neglect from being reported under State law to appropriate State or local authorities. 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
      • We may release your personal health information for any purpose required by law
      • We may release your personal health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations
      • We may release your personal health information as required by law if we suspect child abuse or neglect
      • We may also release your personal health information as required by law if we believe you to be a victim of abuse, neglect, exploitation or domestic violence
      • We may release your personal health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls
      • We may release your personal health information 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
      • We may release your personal health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings
      • We may release your personal health information if required to do so by subpoena or discovery request; in some cases you will have notice of such release
      • We may release your personal health information to law enforcement officials as required by law to report wounds, injuries and crimes; We may release your personal health information to coroners and/or funeral directors consistent with law
      • We may release your personal health information if necessary to arrange an organ or tissue donation from you or a transplant for you
      • We may release your personal health information in limited instances if we suspect a serious threat to health or safety
      • We may release your personal health information if you are a member of the military as required by armed forces services
      • We may also release your personal health information if necessary for national security or intelligence activities
      • We may release your personal health information to workers' compensation agencies if necessary for your workers' compensation benefit determination
    • Ohio law requires that we obtain a consent from you before:
      • Disclosing your personal health information to the Long Term Care Ombudsman regarding your stay in our long-term care facility
      • Disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition
      • Disclosing information about mental health services you may have received
RIGHTS THAT YOU HAVE

  • Access to Your Personal Health Information
    • You have the right to 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
    • We will charge you a search and copying fee if you request a copy of the information. We will also charge for postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary
      • In accordance with the provisions of House Bill 508, the applicable fees for obtaining a copy of your health information are as follows:
        • Pages 1-10: $1.00 per page
        • Pages 11-50: $0.50 per page
        • Pages 51 and up: $0.20 per page
        • Records Copied from Microfiche: $5.00 retrieval fee. $1.00 per page copied
        • Search Fees: $5.00 for records retained in off-site storage
        • Postage: The actual cost of any related postage incurred by Barnesville Hospital for the mailing of record copies
        • Radiology Films: $5.00 per sheet
      • There is no charge for copies of records required for continuation of your medical care
      • For copies of your medical information requested by the Bureau of Workman's Compensation, the Industrial Commission, the Ohio Department of Job and Family Services, or for support of a Social Security disability benefits claim, the first copy will be provided at no cost. However, additional copies will be subject to the charges listed above
    • You may obtain an access request form from:
      Barnesville Hospital Association
      Medical Records Department
      P.O. Box 309
      639 West Main Street
      Barnesville, OH 43713-0309
  • Amendments to Your Personal Health Information
    • You have the right to request in writing that personal health information that we maintain about you be amended or corrected
      • We are not obligated to make all requested amendments but will give each request careful consideration
      • All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request
      • If an 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
      • You may obtain an amendment request form from:
        Barnesville Hospital Association
        Medical Records Department
        P.O. Box 309
        639 West Main Street
        Barnesville, OH 43713-0309
  • 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
      • Accounting request forms are available from:
        Barnesville Hospital Association
        Medical Records Department
        P.O. Box 309
        639 West Main Street
        Barnesville, OH 43713-0309
      • The first accounting in any 12-month period is free; you will be charged a fee of $5.00 for each subsequent accounting you request within the same 12-month period
  • Restrictions on Use and Disclosure of Your Personal Health Information
    • You have the right to request restrictions on certain uses and disclosures of your personal health information for treatment, payment, or health care operations
      • A restriction request form can be obtained from:
        Barnesville Hospital Association
        Medical Records Department
        P.O. Box 309
        639 West Main Street
        Barnesville, OH 43713-0309
      • We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and 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 or orally, any agreed-to restriction by sending such termination notice to:
        Attention: Privacy Officer
        Barnesville Hospital Association
        P.O. Box 309
        639 West Main Street
        Barnesville, OH 43713-0309
  • Complaints
    • If you believe your privacy rights have been violated, you can file a complaint by calling the Barnesville Hospital Complaint Hotline: 740-425-5046
    • You may send a written complaint to:
      Attention: Privacy Officer
      Barnesville Hospital Association
      P.O. Box 309
      639 West Main Street
      Barnesville, OH 43713-0309
    • You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights
    • 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 Barnesville Hospital's Privacy Officer at the following address or by e-mail:
       Attention: Privacy Officer
       Barnesville Hospital Association
       P.O. Box 309
       639 W. Main Street
       Barnesville, OH 43713
       Email: gramby-1@medctr.osu.edu

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. Please include your full name and return address when submitting a request by mail or e-mail.

EFFECTIVE DATE

This Notice of Privacy Practices is effective April 14, 2003

The terms of this Notice of Privacy Practices apply to Barnesville Hospital Association, operating as a clinically integrated health care arrangement composed of Barnesville Hospital Association, Inc., Barnesville Hospital Home Health Agency, Belmont County Health Services - Morristown Pharmacy and Home Care, and Belmont Professional Associates - Morristown Family Practice. All of the entities listed will share the personal health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.