651 West Marion Rd
Mt. Gilead, OH 43338
(419) 946-5015

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 that may include procedures, medications, tests, etc. We may also release your personal health information to another healthcare 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 Healthcare Operations
We will use and disclose your personal 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 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 healthcare facility, healthcare 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 family, friends, and others 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 personal health information to one or more of these outside persons or organizations who assist us with our healthcare 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 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 the hospital’s Privacy Officer. (See "For Further Information.")

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.

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.

We may release your personal health information:

• for any purpose 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 personal health information as required by law if we believe you to be a victim of abuse, neglect, or 
  domestic violence;

• 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 healthcare to you at the request of your employer to determine workplace-related ill-ness 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 some cases you will have notice of such release;

• to law enforcement officials as required by law to report wounds and injuries and crimes;

• to coroners and/or funeral directors consistent with law;

• if necessary to arrange an organ or tissue donation from you or a transplant for you;

• if in limited instances we suspect a serious threat to health or safety;

• 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; and

• 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; or disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition.

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 legal representative. We will charge you per page, as set forth by Ohio law, 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. You may obtain a copy of our fee schedule as well as an Authorization To Release Medical Information form from the Health Information Management Department.

Corrections 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 legal 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 the Health Information Management Department.

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 legal representative. Accounting request forms are available from the Health Information Management Department. The first accounting in any 12-month period is free; you will be charged a fee, as set forth by Ohio law, 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 healthcare operations. A restriction request form can be obtained from the Health Information Management 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 or orally, any agreed-to restriction by sending such termination notice to the Health Information Management Department.

Complaints.
If you believe your privacy rights have been violated, you can file a complaint with the hospital’s Risk Manager. You may also file a complaint with the Secretary of the U.S. Department of Health and man 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.

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 following:

Morrow County Hospital
651 W. Marion Rd.
Mt. Gilead, OH 43338
(419) 946-5015
Privacy Officer- (419) 949-3046
Risk Manager- (419) 949-3183

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.

EFFECTIVE DATE 
This Notice of Privacy Practices is effective August 1, 2004.