Orthopaedic Surgeons Division
Notice of Privacy Practices
NOTICE, WHICH IS EFFECTIVE AS OF April 14, 2003, DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
doctors and staff here at Toledo Orthopaedic Surgeons Division believe
your medical information should remain confidential. The law requires
us to establish office policies that are designed to safeguard your
health information. The information contained in this notice
constitutes our promise to you that we acknowledge our legal obligation
to protect your health information, and it describes your rights
concerning our use of your health information.
We will use and disclose your health information
treatment, payment and/or health care operations.
Treatment means the provision, coordination, or management of health
care and related services by one or more health care providers,
including the coordination or management of health care by a health
care provider with a third party; consultation between health care
providers relating to a patient; or the referral of a patient for
health care from one health care provider to another. For example, a
consultation follow up letter from a specialist to your primary care
physician would be medical information maintained for treatment
2. Payment means activities undertaken by a
health care provider or health plan to obtain or provide reimbursement
for the provision of health care. For example, the medical information
furnished to your insurance company so that we may be paid for our
services is considered information maintained for payment purposes.
Health Care Operations includes certain activities of the practice, as
well as activities of an organized health care arrangement in which we
participate, including: quality assessment and improvement activities,
reviews of the competence or qualifications of health care
professionals, activities related to underwriting or premium rating of
insurance contracts, activities related to legal or accounting services
provided to the practice, and business management and planning. For
example, from time to time hospitals and insurance companies will
review physicians’ clinical skills in order to assure that quality care
is being provided. When such reviews are conducted, it is often
necessary for the reviewer to randomly select and examine patients’
We are permitted or required to disclose
limited health information about you, without your authorization, in
the following circumstances:
1. As required by law so long as it is limited
requirements of such law.
For public health activities, including the prevention and control of
disease, vital statistics, and public health investigations.
3. For purposes of making required reports about
neglect or domestic violence.
Health oversight activities, including audits, civil, criminal or
administrative investigations, proceedings or actions; inspections;
licensure or disciplinary actions.
5. Judicial and administrative proceedings, in
Law enforcement purposes (i.e., reports of gunshot wounds; grand jury
subpoenas; and information regarding victims of crime).
coroners, medical examiners and funeral directors for purposes of
identifying deceased persons or determining cause of death.
8. For organ and tissue donation, consistent
Research, provided the federal regulations governing research
activities that insure the privacy of your health information are met.
10. To avert serious threats to health or safety.
Specialized government functions regarding military personnel and
military veterans, certain national security purposes, and inmates.
12. Workers’ compensation to the extent
necessary to comply
Marketing, for purposes of appointment reminders, treatment
alternatives, or other related benefits and services that may be of
interest to you.
Any uses or disclosures other than those noted
above require us to obtain your written authorization, which you may
revoke at any time. Any such revocation must be in writing.
You have the following rights with respect to
The right to request restrictions on certain uses of your health
information, however we are not required to agree to your request.
The right to request, in writing, the manner or method by which we
contact you to furnish confidential communications about your health
information (i.e., fax, e-mail, voice mail, etc.). You are obligated to
notify us, in writing, of any changes to your request.
right to inspect your health information (you are entitled to receive a
copy of your health information, except for psychotherapy notes and
information compiled in anticipation of or for use in, a civil,
criminal, or administrative action or proceeding).
4. In limited
circumstances, the right to ask us to amend your health information,
however we reserve the right to deny your request. If your request to
amend is denied, we will provide you with information about the basis
of our denial and your right to submit a written statement disagreeing
with our denial.
5. The right to receive an accounting of
disclosures of your health information, except those disclosures
related to treatment, payment or health operations, disclosures that
are made to you, disclosures made for national security purposes or to
correctional institutions or law enforcement officials, or disclosures
that were made prior to the compliance date.
6. The right to receive a copy of this Notice in
We have the following obligations:
We are required by law to maintain the privacy of your health
information, and we are required to provide you with a notice of our
legal duties and privacy practices.
2. We are required to abide the terms of the
We are required to advise you of any changes we make in the terms of
our notice of privacy practices. If any changes are made to notice of
privacy practices, we will post the revised notice and make a copy of
it available on request.
you believe we have violated your privacy rights, you may file a
written complaint to our Privacy Officer and/or to the Secretary of
Health and Human Services. There will be no retaliation for filing a
If you want more information or you believe your
have been violated, you can contact Our Privacy Officer at the
following address: Toledo Orthopaedic Surgeons Division, 2865 N.
Reynolds Rd. Suite 160, Toledo, Ohio 43615, Attention Privacy Officer.
Our telephone number is 419-578-7200. Alternatively, you may wish to
contact the federal agency in charge of enforcing patients’ privacy
rights. That address is: Office for Civil Rights, U.S. Department of
Health and Human Services, 200 Independence Ave., S.W., Room 509F, HHS
Building, Washington, D.C. 20201.