PRE-ADMISSION FORM (Hospital Patients Only)

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Privacy Notice

To our valued customers,

Trust and confidentiality is essential in healthcare. If you entrust Wayne Hospital with your healthcare needs, it is up to us to safeguard your personal health information (PHI).

We value your trust in us, in the information you share with us and we are dedicated to protecting your privacy and confidentiality.

If you have questions or need further assistance regarding this Notice, you may contact the  Privacy Officer at Wayne Hospital, 835 Sweitzer Street, Greenville, Ohio 45331.

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 describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The terms of this Notice of Privacy Practices apply to Wayne Hospital and Medical Staff of Wayne Hospital, operating as a clinically integrated health care arrangement. The members of this health care arrangement will share personal health information of our 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 patient’s personal health 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 Wayne Hospital’s Information Desk.

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 involve 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.

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, i.e. insurance companies.

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 management, accreditation, licensing, etc.

OUR FACILITY DIRECTORY: We maintain a facility directory listing your name, room number, and general condition. Unless you choose to have your information excluded from this directory, the information will be disclosed to anyone who requests it by asking for you by name. 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 for your care in order to facilitate that person’s involvement in caring for you or paying for your care. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster 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 your personal health information to one or more of these outside persons or organizations who assists us with our health care operations. We require these business associates to safeguard the privacy of your information.

FUNDRAISING: We may contact you to donate 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 Wayne Hospital 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 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 Wayne Hospital.

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.

 We may release your personal health information for:

- Any purpose required by law;

- Public health activities, such as required reporting of disease, injury, birth and death, and for required public health investigations;

- As required by law,  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 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.

- 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, 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 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.

- If in limited instances we suspect a serious threat to health or safety.

 

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 authorized representative. We will charge you 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. You may obtain an access request form from Health Information Management.  You have the right to obtain an electronic copy of your health information that exists in an electronic format and you may direct that the copy be transmitted directly to an entity or person designated by you, ,provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information.

AMENDMENTS TO YOUR PERSONAL HEALTH INFORMATION. You have the right to request in writing that personal 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 authorized 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 Health Information Management.

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 authorized representative. Accounting request forms are available from Health Information Management. The first accounting in any 12-month period is free; you will be charged a reasonable fee for each subsequent accounting you request within the same 12-month period.  When you request an accounting of disclosures of your electronic health record, the accounting will be for three years prior to the date of the request for the accounting and will include, in addition to all types of disclosures listed in the general policy, disclosures for treatment, payment and health care operations.  [For electronic health records acquired as of January 1, 2009, these requirements will apply to disclosures made by the organization from such a record on and after January 1, 2014.  For electronic health records acquired after January 1, 2009, these requirements will apply to disclosures made by the organization from such a record on and after the later of January 1, 2011 or the date that it acquires an electronic health record.]

RESTRICTIONS ON USE AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION. You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. A restriction request form can be obtained from Health Information Management. 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 to sending such termination notice to Health Information Management.

COMPLAINTS. If you believe your privacy rights have been violated, you can file a written complaint to Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, C.D. 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 Practice Practices.