Patient Information

Patient Privacy Policy

With your consent, the Practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
 
Examples of uses of your health information for treatment purposes
A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist, family doctor, orthodontist, or family dentist in the area. The doctor will share the information with such medical doctors and obtain input.
 
Examples of use of your health information for payment purposes
We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.
 
Example of use of your information for health care operations
We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
 
Your health information rights
The health record we maintain and billing records are the physical property of the Practice. The information in it, however, belongs to you. You have a right to:
  • Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted.
  • Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office;
  • Request that you be allowed to inspect and copy your health record and billing record-you may exercise this right by delivering the request in writing to our office;
  • Appeal a denial of access to your protected health information except in certain circumstances;
  • Written request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office;
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our State Street office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our State Street office; and,
  • Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
 
If you want to exercise any of the above rights, please contact our office manager who will provide you with assistance. Please direct all inquiries by phone to (260) 423-2340, in writing to 4606-D East State Blvd., Fort Wayne, IN, 46815, or in person during normal business hours,
 
You have the right to review this Notice authorizing use and disclosure of your protected health information for treatment, payment, and health care operation purposes.
 
Our responsibilities
The practice is required to:
  • Maintain the privacy of your health information as required by law;
  • Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
  • Abide by the terms of the Notice;
  • Notify you if we cannot accommodate a requested restriction or request; and
  • Accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling (260) 423-2340, visiting our State Street office, or visiting our web site at www.omsafw.com.
 
To request information or file a compliant
 
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our office manager at (260) 423-2340.
 
Additionally, if you believe your privacy rights have been violated, you may file a written complaint to our office manager at our State Street office. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address is:
 
US Department of Health and Human Services
200 Independence Ave., SW
Washington, D.C. 20201
(877) 696-6675
hhs.mail@hhs.gov
     
  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Other disclosures and uses
 
Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
 
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to the person's involvement in your care or in payment for such care if you do not object or in an emergency.
 
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements
 
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation and filing your claim. We may also request a release of information to be completed by you prior to furnishing additional health information that may be requested by your Worker Compensation carrier.
 
Public Health
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
 
Abuse and Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
 
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institutions, or its agents, your protected health information necessary for your health and safety of other individuals.
 
Law Enforcement
We may disclose your protected health information to appropriate health oversight agencies or for oversight activities.
 
Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
 
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceedings as allowed or required by law, with your consent, or as directed by a proper court document.
 
Research
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
 
Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts.
 
Funeral Directors
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
 
Organ Procurement Organizations
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
 
Marketing
We may contact you to provide you with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.
 
For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law, such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
 
Other Uses
Other uses and disclosure besides those identified in the Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorizations as previously provided.
 
Website
This Notice will be on our website at www.omsafw.com.
 
 
Effective Date: January 1, 2003