Notice of Privacy Practices
Effective April 5, 2021
Notice of Privacy Practices PDF
This Notice tells you how your medical information may be used or shared. It also tells how you can get your information. Please read it carefully. Ask us if you have any questions, or call the Privacy Officer at (419) 557-6913.
Why We Keep Information About You
We keep medical information about you to help care for you and because the law requires us to. The law also says we must:
- protect your medical information;
- give you this Notice; and
- follow what this Notice says.
What the Words We Use Mean
“Notice” means this Notice of Privacy Practices.
“FRHS” means Firelands Regional Health System, Firelands Regional Medical Center Main and South Campuses, Route 4 Surgery Center, all offsite locations, our staff, volunteers, contractors and any affiliated organizations covered by the Notice, including but not limited to: Firelands Physician Group, Firelands Counseling and Recovery Services, Firelands Corporate Health, Firelands DME Company, Firelands Home Health, Firelands MSO, Firelands Vocational Rehabilitation Services, and Firelands Physicians Regional Health Care.
“We,” “our,” or “us” means one or more FRHS organizations, providers, or staff.
“You” means the patient that the medical information is about.
“Medical information” means all the paper and electronic records related to a patient’s physical and mental health care—past, present, or future. These records tell who the patient is and includes information about billing and payment.
“Use” means sharing or using medical information within FRHS.
“Share” means giving medical information, or access to information, to someone outside FRHS.
How We May Use and Share Information about You
We use electronic record systems to manage your care. These systems have safeguards to protect the information in them. We also have policies and training that limit the use of information to those who need it to do their job. Doctors and other people who are not employed by FRHS may share information they have about you with our employees in order to care for you. Hospitals, clinics, doctors and other caregivers, programs, and services may share medical information about you without your consent for many reasons. Here are a few examples:
We may use and share medical information to treat you. For example, a doctor treating you for a broken leg will need to know if you have diabetes because diabetes can slow healing. The doctor may need to tell food services that you have diabetes so the right meals can be prepared for you. We may also share medical information about you so that you can get:
- medicine, medical equipment, or other things you need for your health care;
- lab tests, x-rays, transportation, home care, nursing care, rehab, or other health care services.
Medical information may also be shared when needed to plan for your care after you leave FRHS.
For Billing and Payment
We may use and share your information so that we and others who have provided services to you can bill and collect payment for these services. For example, we may share your medical information with your health plan:
- so your health plan will pay for care you received at FRHS
- to get approval before doing a procedure
- so your health plan can make sure they have paid the right amount to FRHS.
We may also share your information with a collection agency if a bill is overdue.
For Business Reasons
We may use and share information about you for business reasons. When we do this, we may, if we can, take out information that identifies who you are. Some of the business reasons we may use or share your medical information include:
- to follow laws and regulations;
- to train and educate;
- for credentialing, licensure, certification, and accreditation;
- to improve our care and services;
- to budget and plan;
- to do an audit;
- to maintain computer systems;
- to evaluate our staff;
- to decide if we should offer more services;
- to find out how satisfied our patients are; and
- to bill and collect payment.
Anyone we share information with in order to do these tasks on behalf of us must also protect and restrict the use of your medical information.
For Health Information Exchanges
We will disclose some of your protected health information to one or more approved Health Information Exchanges (HIE) for the purpose of facilitating the provision of health care to you, as permitted by law. An HIE is an electronic network to facilitate secure transmission of health information between health care providers. Only authorized individuals may access and use your protected health information for the HIE. We may also use the HIE to disclose information for public health reporting purposes, for example, immunization reporting. The HIE maintains appropriate administrative, physical and technical safeguards to protect the privacy and security of your protected health information.
You or your personal representative have the right to request in writing at any time that we do not disclose any of your protected health information to the HIE (“opt out”). Send this written request to the FRHS Privacy Officer, 1111 Hayes Ave., Sandusky, Ohio 44870. We must honor any written request to opt out of the HIE. If you decide to opt out, your data remains in the electronic system, but providers will be blocked from viewing the data. Any restrictions that you place on the disclosure of your protected health information to the HIE may result in a health care provider not having access to information that is necessary to render appropriate care to you.
To Contact You about Appointments, Insurance, and Other Matters
We may contact you by mail, phone, text, or email for many reasons, including to:
- remind you about an appointment
- register you for a procedure
- give you test results
- ask about insurance, billing, or payment
- follow up on your care
- ask you how well we cared for you.
We may leave voice messages at the telephone number you give to us.
To Tell You about Treatment Options or Health-related Products and Services
We may use or share your information to let you know about treatment options or health-related products or services that may interest you.
We may use your name, address, phone number, the dates and places you received services at FRHS, and the names of your doctors to contact you for fundraising purposes for FRHS. You have the right to ask not to be contacted for fundraising. If you do not want us to contact you for fundraising efforts, you must notify the Privacy Officer using the contact information provided in this Notice. We will process your request promptly but may not be able to stop contacts that were initiated prior to receiving your opt-out notice.
For the Hospital Directory
With the exception of Behavioral Health patients, if you are admitted to the hospital,your name, where you are in the hospital, your general condition (such as “fair” or “stable”), and your religion are included in the patient directory at the information desk. This helps family, friends, and clergy visit you and be informed about your condition. Except for your religion, this information may be shared with visitors or phone callers who ask for you by name. Unless you tell us not to, your religion may be shared with a member of the clergy, such as a priest, rabbi, or imam even if you aren’t asked for by name.
You may opt out of the directory. If you opt out of the directory we will not share your information even if you are asked for by name.
To Inform Family Members and Friends Involved in Your Care or Paying for Your Care
With the exception of Behavioral Health patients, we may share information about you with family members and friends who are involved in your care or paying for your care. Whenever possible, we will allow you to tell us who you would like to be involved in your care. However, in emergencies or other situations in which you are unable to tell us who to share information with, we will only share information with those legally permitted to receive the information. We may also share information about you with a public or private agency during a disaster so that the agency can help contact your family or friends to tell them where you are and how you are doing.
We may use and share medical information about you for the research we do to improve public health and develop new knowledge. For example, a research project may compare the health and recovery of patients who received one medicine for an illness to those who received a different medicine for the same illness. We use and share your information for research only as allowed by federal and state rules. Each research project is approved through a special process that balances the research needs with the patient’s need for privacy. In most cases, if the research involves your care or the sharing of medical information that can identify you, we will first explain to you how your information will be used and ask your consent to use the information. We may access your medical information before the approval process to design the research project and provide the information needed for approval. Health information used to prepare a research project does not leave FRHS.
To Stop a Serious Threat
We may share your medical information to prevent a serious and urgent threat to the health and safety of you or someone else, as authorized or required by law.
For Organ, Eye, and Tissue Donation
We share medical information about organ, eye, and tissue donors and about the patients who need the organs, eyes, and tissues, with others involved in obtaining, storing, and transplanting the organs, eyes, and tissues.
With Military Authorities
If you are a member or veteran of the armed forces, we may share your medical information with the military as authorized or required by law. We may also share information about foreign military personnel to the proper foreign military authority.
For Worker’s Compensation
We may share your medical information as authorized by laws relating to worker’s compensation or similar programs.
For Health Oversight and Public Health Reporting
We may share information for audits, investigations, inspections, and licensing with agencies that oversee health organizations.
We may also share your medical information in reports to public health agencies.
Some reasons for this include:
- to prevent or control disease and injuries
- to report certain kinds of events, such as births and deaths
- to report abuse or neglect of children, elders, or dependent adults
- to report reactions to medicines or problems with medical products
- to inform people about recalls of medical products they may be using
- to let someone know that they may have been exposed to a disease or may spread a disease
- to notify the authorities as authorized or required by law that a patient has been the victim of abuse, neglect, or domestic violence.
For Lawsuits and Disputes
We may share your medical information as directed by a court order, discovery request, or other lawful instructions from a court or authorized government agency when needed for a legal or administrative proceeding.
With Law Enforcement and Other Officials
We may share your medical information with a law enforcement official as authorized or required by law.
We May Also Share Your Medical Information with:
- coroners, medical examiners, and funeral directors, so they can carry out their duties
- federal officials for national security and intelligence activities
- a correctional institution if you are an inmate
Other Uses of Your Medical Information
We will not use or share your medical information for reasons other than those described in this Notice unless you agree in writing. For example, you may want us to give medical information to your employer. We will do this only with your written approval.
We are not permitted to use your information in order to conduct marketing activities unless you have specifically authorized the communication.
Psychotherapy notes are notes recorded by a mental health professional that document or analyze the contents of a conversation in a counseling session and are kept separated from the rest of your medical record. There are limited circumstances in which we will use or disclose psychotherapy notes without a written authorization from you. The originator of the notes may use them for treatment purposes. We may use psychotherapy notes in our own mental health counseling training programs. We may also use psychotherapy notes in defense of a legal action or other proceeding brought by you, as required by law, or to avert a serious threat to a person’s or the public’s health or safety.
Sale of Protected Health Information
We are not permitted to sell your information unless you have specifically authorized the disclosure.
Your Rights Regarding Your Medical Information
The records we create and maintain using your medical information are the custody of FRMC, but you have the following rights:
Right to Review and Receive a Copy of Your Medical Information
You have the right to look at and receive a copy of your medical information, including billing records. You must make your request in writing and it must be signed by you or your representative. We may charge a fee to cover copying, mailing, and other costs and supplies. In rare cases, we may deny your request for certain information. If we deny your request, we will give you the reason why in writing. Medical Record locations for our providers are listed at the end of this notice.
Right to Ask for a Change in Your Medical Information
If you believe the information we have about you is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. The request must be made in writing and directed to the Health Information Management Department of our providers listed at the end of this notice. We cannot remove any information from the record. We can only add new information to complete or correct the existing information. We may deny your request; if we deny your request we will state in writing why we denied your request.
Right to Ask For a List of When Your Medical Information Was Shared
You have the right to ask for a list of when your medical information was shared without your written consent. This list will NOT include uses or sharing:
- for treatment, payment, or business reasons
- with you or someone representing you
- with those who ask for your information as listed in the hospital directory
- with family members or friends involved in your care
- in those very few instances where the law does not require or permit it
- as part of a limited data set with direct identifiers removed
- releases before April 14, 2003.
You must request this list in writing from the Privacy Officer at the address listed at the end of this Notice. Your request must state the time period for which you want the list. The time period may not be longer than 6 years from the date of your request. You may be charged reasonable copying and mailing fees associated with this list.
Right to Notice in Case of a Breach
You have a right to know if your information has been breached (unauthorized acquisition, access, use, or disclosure of certain categories of health information ). We will follow what the privacy laws require to let you know if your information has been shared in error.
Right to Ask for Limits on the Use and Sharing of Your Medical Information
You may request in writing that we not use or disclose your information for treatment (other than emergency treatment), payment, or operations purposes, or to individuals involved in your care, unless required by law.
We will consider your request and respond, but we are not required to honor the request. However, we will accept a request for a restriction on a disclosure of your information to a health plan for payment or operations purposes, if not otherwise required by law, if the information pertains solely to an item or services for which someone other than a health plan on your behalf has paid in full.
Right to Limit Sharing of Information with Health Plans
If you paid in full for your services, you have the right to limit the information that is shared with your health plan or insurer. To limit this information, you must ask before you receive any services. Let us know you want to limit sharing with your health plan when you schedule your appointment. Any information shared before we receive payment in full, such as information for pre- authorizing your insurance, may be shared. Also, because we have a medical record system that combines all your records, we can limit information only for an episode of care (services given during a single visit to the clinic or hospital). If you wish to limit information beyond an episode of care, you will have to pay in full for each future visit as well.
Right to Ask for Confidential Communications
You have the right to ask us to communicate with you in a certain way or at a certain place. For example, you can ask that we contact you only at work or only using a post office box. You must make your request in writing to the Privacy Officer at the address listed at the end of this Notice. You do not need to tell us the reason for your request. Your request must say how or where you wish to be contacted. You must also tell us what address to send your bills for payment. We will accept all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using any information we have.
Right to Get a Paper Copy of This Notice
You have the right to get a paper copy of this Notice, even if you have agreed to receive it electronically. You may get a copy:
- at any of our facilities
- by contacting the Privacy Officer at the number listed at the end of this Notice or at Firelands.com
Changes to this Notice
We have the right to change this Notice at any time. Any change could apply to medical information we already have about you, as well as information we receive in the future. The effective date of this Notice is on the first page of the Notice. A copy of the current Notice is posted throughout FRHS and at Firelands.com
How to Ask a Question or Report a Complaint
If you have questions about this Notice or want to talk about a problem without filing a formal complaint, please contact the Privacy Officer at (419) 557-6913. If you believe your privacy rights have been violated, you may file a complaint with us. Please send your complaint to the FRHS Privacy Officer at the location listed at the end of this Notice or call the Compliance Hotline at the number listed below. You may also file a complaint with the Office of Civil Rights. You will not be treated differently for filing a complaint.
How to Contact Us
Firelands Regional Health System Privacy Officer
1111 Hayes Avenue
Sandusky, Ohio 44870
Firelands Regional Health System Compliance Hotline
Firelands Regional Medical Center Health Information Management Department
1111 Hayes Avenue
Sandusky, Ohio 44870
Firelands Physician Group Health Information Management Department
1111 Hayes Avenue
Sandusky, Ohio 44870
Firelands Counseling & Recovery Services Medical Records Department
1925 Hayes Avenue
Sandusky, Ohio 44870