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Privacy Practices
Your Authorization and Consent. Except as outlined below, we will not use or disclose your
personal health information for any purpose unless you have a signed a form consenting to or
authorizing the use or disclosure. You have the right to revoke that consent or authorization
in writing unless we have taken any action in reliance on the consent or authorization.
Uses and Disclosures for Treatment. With your signed consent, we will make uses and
disclosures of your personal health information as necessary for your treatment. For instance,
doctors, 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.
Uses and Disclosures for Payment. With your signed consent, we will make uses and
disclosures of your personal health information as necessary for payment purposes. 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. With your signed consent, 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 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.
Our Facility Directory. We maintain a facility directory listing the name, room number,
general condition, 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 and also to restrict
what information is provided and/or to whom.
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 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 to the Privacy Officer together with a statement that you do
not wish to receive fundraising materials or communications from us.
Appointments and Services. We may contact you to provide appointment reminders or
information about treatment alternatives or other health-related benefits and services that may
be of interest to you. 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 Privacy Officer. You also have the right to request that we not send you any future
marketing materials and we will use our best efforts to honor such request. You may make the
request by sending your name and address to the Privacy Officer with your request to be
removed from our marketing mailing lists.
Research. In limited circumstances, we may use and disclose your personal health
information for research purposes. For example, a researcher 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 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.
- 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, 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; 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, civil, or criminal proceedings;
- We may release your personal health information if required to do so by a court or
administrative ordered subpoena or discovery request; in most 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 and 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 from you;
- We may release your personal health information if in limited instances 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; and
- We may release your personal health information to workers' compensation agencies if
necessary for your workers' compensation benefit determination.
We may use certain information (name, address, telephone number, dates of service, age,
and gender) to contact you in the future to raise money for Berger Health Foundation. We
may also provide this name to our institutionally related foundation only, for the same
purpose. The money raised will be used to expand and improve the services and programs we
provide to the community. If you do not wish to be contacted for fund-raising efforts,
please notify the foundation director:
Berger Health Foundation
1204 North Court Street
Circleville, Ohio 43113
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. Depending
on your request, we may charge you a nominal fee per page 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. Please contact
the Privacy Officer or the Director of Medical records with any requests.
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.
Please contact the Privacy Officer or the Director of Medical Records with any requests.
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. The
first accounting in any 12-month period is free; you may be charged a nominal fee 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 aspects of our uses and disclosures of your personal health
information for treatment, payment, or health care operations on the consent form you sign when
you become a patient. 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 the
Privacy Officer.
Complaints. If you believe your privacy rights have been violated, you can submit an oral
or written complaint to the Berger Health System Patient Advocate or the Corporate Compliance
Officer. 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.
If you have questions or need further assistance regarding this Notice, you
may contact the Privacy Officer. 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.
This Notice of Privacy Practices is effective April 14, 2003.
The terms of this Notice of Privacy Practices apply to Berger Health System operating as a
clinically integrated health care arrangement composed of Berger Hospital employees, the
physicians and other licensed professionals seeing and treating patients, Home Health and
Hospice of Pickaway County, Pickaway Health Services, and Pickaway Medical Group. Members of this
clinically integrated health care arrangement work and practice at Berger Hospital and its
affiliated clinics. All of the entities and persons listed will share personal health
information of 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' 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. If you have any questions, comments, or concerns, please contact:
Privacy Officer
Berger Health System
600 North Pickaway Street
Circleville, OH 43113
740.474.2126
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