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.

Mark A. VanMeter, Group Practice Manager 

This Notice of Privacy Practices describes how Columbus Obstetricians - Gynecologists, Inc. ("COG") may use and disclose your Protected Health Information. It also describes your right to access your Protected Health Information. “Protected Health Information" is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 

COG is required to abide by the terms of this Notice of Privacy Practices. COG may change the terms of its notice, at any time. You may obtain a copy of the current Notice of Privacy Practices at any time by accessing our website, ColumbusObGyn.com, by calling the office and requesting that a copy be sent to you in the mail, or by asking for one at the time of your next appointment. 

1. Uses of Protected Health Information

 COG will maintain all medical records and Protected Health Information in confidence as required by law. You will be asked by COG to sign a consent form that will permit COG to use and disclose your Protected Health Information for treatment, payment, and health care operations. For example: 

• Treatment: COG may use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. For example, COG would disclose your Protected Health Information, as necessary, to a home health agency that provides care to you. COG may also disclose Protected Health Information to other physicians who may be treating you. 
• Payment: Your Protected Health Information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant Protected Health Information be disclosed to your health plan. 
• Healthcare Operations: COG may use or disclose, as-needed, your Protected Health Information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, COG may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician, and COG may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment. COG may notify you of certain test results via U.S. Postal Service. COG may also leave a voice mail at your home or work.
  COG may use or disclose your Protected Health Information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you or for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services COG offers. COG may also send you information about products or services that COG believes may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.
  Other uses and disclosures of your Protected Health Information will not be made unless COG has obtained your written authorization or unless it is otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or COG has taken an action in reliance on previous authorization. 
  

2. Your Rights

You have the right to inspect and copy your Protected Health Information. This means you may inspect and obtain a copy of Protected Health Information about you that is contained in a designated record set for as long as COG maintains the Protected Health Information. A "designated record set" contains medical and billing records and any other records that your physician and COG uses for making decisions about you. It does not include psychotherapy notes, information compiled in anticipation of or used in a legal or administrative proceeding, or information protected by law from individual access. Please contact our Privacy Officer if you have questions about access to your medical records. 

 You may request a restriction on the use or disclosure of your Protected Health Information. This means you may ask us not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your Protected Health Information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. If your physician believes it is in your best interest to permit use and disclosure of your Protected Health Information, your Protected Health Information will not be restricted. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by specifically identifying the restricted information in writing and mailing it to COG's Privacy Officer. 

 You have the right to request to receive confidential communications from us by alternative means or at an alternative location. COG will accommodate reasonable requests. COG may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Please make this request in writing to our Privacy Officer. 

 You may request that your physician amend your Protected Health Information. If COG denies your request for amendment, you have the right to file a statement of disagreement with us and COG may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. 

 You have the right to receive an accounting of certain disclosures occurring after April 14, 2003 that COG has made, if any, of your Protected Health Information. This right does not apply to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices or to disclosures COG may have made to you, to family members or friends involved in your care, or for notification purposes.  

3. Complaints

If you believe COG has violated your privacy rights, you may file a complaint with us by notifying our Privacy Officer. COG will not retaliate against you for filing a complaint. 

 You may contact our Privacy Officer, Mark A. VanMeter at (614) 434-2400, extension 115 or mvanmeter@columbusobgyn.com for further information about the complaint process. You may also report your complaint to the Office of Civil Rights, Regional Manager, Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, Illinois 60601. 

 This notice was published and becomes effective on April 14, 2003.