Explanation of Forms. 10 Wilmington Place handles medical information about you, and how that information is handled is regulated by law. To comply with the applicable law, 10 Wilmington Place requires you to receive this notice and, in some circumstances, to sign an authorization form.
10 Wilmington Place is allowed by law to use and disclose information about you for the purposes essential to providing care, including, but not limited to, treatment, payment collection or healthcare operations.
An authorization allows 10 Wilmington Place to use and disclose information about you for any other reason that is listed in the authorization. 10 Wilmington Place may not refuse to admit or treat you for refusing to sign the authorization. Other rules about your rights regarding medical information are described in this notice.
Uses and Disclosures for Treatment, Payment and Operations. Medical information about you may be used or disclosed by 10 Wilmington Place for treatment, payment, and health care operations without your authorization. Treatment includes consultation, diagnosis, provision of care, and referrals. Payment includes all of the things necessary for billing and collection, such as claims processing. Health care operations includes things 10 Wilmington Place does to assess the quality of care, train staff, and manage 10 Wilmington Place’s business. Some examples of disclosures and use are below.
Example of Treatment Disclosure. 10 Wilmington Place may disclose medical information about you to your treating physician, a hospital or other providers to help them diagnose and treat an injury or illness.
Example of Payment Disclosure. 10 Wilmington Place may disclose medical information about you when Medicare, Medicaid, or other payors require the information before paying for your health care services.
Example of Health Care Operations Use. 10 Wilmington Place may use medical information about you when it hires new staff whose training requires information about the medical needs of our residents.
Other Uses and Disclosures. We may use or disclose your protected health information in the following situations without your authorization. These situations include:
As Required By Law. We may use or disclose your medical information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health. We may disclose your medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your medical information, if directed by the public health authority, to another government agency that is collaborating with the public health authority.
Communicable Diseases. We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight. We may disclose medical information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect. We may disclose your medical information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your medical information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration. We may disclose your medical information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.
Legal Proceedings. We may disclose your medical information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement. We may also disclose your medical information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (1)legal processes and as otherwise required by law; (2) limited information requests for identification and location purposes; (3) pertaining to victims of a crime; (4) suspicion that death has occurred as a result of criminal conduct; (5) in the event that a crime occurs on the premises of10 Wilmington Place; and (6) medical emergency (not on 10 Wilmington Place’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation. We may disclose your medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your medical information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. We may disclose such information in reasonable anticipation of death. Your medical information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research. We may disclose your medical information to researchers when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your medical information.
Criminal Activity. Consistent with applicable federal and state laws, we may disclose your medical information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security. When the appropriate conditions apply, we may use or disclose medical information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your medical information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation. Your medical information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates. We may use or disclose your medical information if you are an inmate of a correctional facility and your physician created or received your medical information in the course of providing care to you.
Required by Secretary of HHS. Under the law, we must make disclosures to you and to the Secretary of the Department of Health and Human Services when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the law.
10 Wilmington Place Directories. Unless you object, we will use and disclose in our 10Wilmington Place directory your name, the location at which you are receiving care, your condition(in general terms), and your religious affiliation. Members of the clergy will be told your religious affiliation.
Others Involved in Your Healthcare. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose your medical information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your medical information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Authorized Uses and Disclosures. Additional uses and disclosures of your medical information may be made if you have given written authorization, which may be revoked at any time in writing delivered to the Executive Director, except to the extent 10 Wilmington Place acted in reliance on the authorization.
We may only use or disclose your medical information in the following situations with your authorization. These situations include:
Marketing. We are required to obtain your authorization to use or disclosure your medical information for marketing purposes.
Sale of Protected Health Information. We may not sell your medical information without your authorization.
Psychotherapy Notes. In most cases, we must obtain your authorization to disclose psychotherapy notes. Psychotherapy notes are notes of a mental health professional from a counseling session that are maintained separate from the rest of your medical record.
Other Uses and Disclosures. We will not use or disclosure your medical information for any reason that is not described in this notice without your authorization.
Restrictions. You have the right to request restrictions on the information we use and disclose for purposes of treatment, payment, and carrying out our operations, or information we disclose to your family, friends or relatives; however, 10 Wilmington Place will only be bound by the restrictions if10 Wilmington Place notifies you that it agrees with them.
If you pay for a service or health care item out-of-pocket, in full, you can request that we not share that information with your health insurer for the purpose of payment or carrying out our operations. We must agree to this request unless the disclosure of the information is required by law.
Confidentiality. You have the right to have 10 Wilmington Place use only confidential means of communicating with you about medical information. This means you may have information delivered to you at a certain time or place, or in a manner that keeps your information confidential.
Access. You have the right to see and receive a copy of information about you kept by 10Wilmington Place under most circumstances.
You shall have access to your medical information upon request, except in instances where your treating physician determines that it would not be medically advisable to provide the information to you, in which case the information will be provided to your legal representative.
Excluding weekends and holidays, you or your legal representative will have access to medical information within twenty-four (24) hours of the request for access. Should you or your legal representative wish to obtain a photocopy of your medical information, copies shall be provided by 10 Wilmington Place upon two (2) working days notice.
Amendment. You have the right to have 10 Wilmington Place amend its records of information about you. 10 Wilmington Place may refuse to amend information that is accurate, that was created by someone else, or cannot be disclosed to you.
Accounting. You have the right to see a list of disclosures of medical information about you by 10Wilmington Place, which includes the purposes and recipients of the information.
Copy. You have the right to receive a paper copy of this notice.
Privacy Notice. 10 Wilmington Place is required by law to keep medical information about you private and to give you this notice. 10 Wilmington Place must abide by this notice. However, 10Wilmington Place reserves the right to amend this notice and make such changes applicable to all medical information maintained by 10 Wilmington Place. Any revised notice will be provided to you.
Breach. You have the right to be notified promptly if a breach occurs that may have compromised the privacy or security of your information.
Fundraising. We may contact you for fundraising efforts, but you have the right to tell us not to contact you in the future.
Complaints. You may complain to 10 Wilmington Place if you believe your privacy rights have been violated by giving a written complaint to the Administrator. You may also complain to the Secretary of the U.S. Department of Health and Human Services. 10 Wilmington Place will not retaliate against you for making a complaint.
Contact. For more information or to file a complaint please contact the Administrator at info@10wilmingtonplace.com or phone (937) 253-1010.
Effective Date. This notice is effective until revised by 10 Wilmington Place.
10 Wilmington Avenue Dayton, Ohio 45420
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