Notice of Privacy Practices

This notice describes how federal and state law requires us to maintain the privacy of your health information, how that information may be used and disclosed, and how you may gain access to that information. This notice is effective as of March 1, 2004.

We use and disclose your health information for:

• treatment
• payment
• healthcare operations
• notifying persons involved in your care in an emergency or if you are incapacitated (we will use our professional judgment)
• situations when we are required by law
• meeting national security requirements (military, federal officials, or a correctional institution or law enforcement officer with legal custody)
• our reasonable belief that you are a possible victim of abuse, neglect, domestic violence or other crimes
• averting a serious threat to your (or anyone else’s) health and safety
• appointment reminders (telephone messages, written correspondence)

Your written authorization is needed to disclose your health information to any other person for any other purpose other than those described above.  You may revoke your authorization in writing at any time. This includes family or friends that you desire to help with your care or related service providers for marketing purposes.

You have the right to:

• view or receive copies of your health information.  You must request access to your records in writing. We will charge a reasonable, cost-based fee for our expenses.  We will charge $.15 for each page copied, $15 per hour for staff time to locate and copy your information and any postage needed for mailing.  If you request a format other than photocopies, we will provide it, if possible, with applicable fees.  If you request a summary of your information, we will provide it with applicable fees.
• receive a record of instances when we disclosed your health information for reasons other than those listed above, for the last 6 years, but not prior to March 1, 2004.
• request that we consider placing additional restrictions on our use or disclosure of your health information.
• request in writing that we offer you your information by other means or to a different location or that we amend your information. 

We reserve the right to make lawful changes to our Privacy Practices at any time.  If we do make a change, this Notice will be revised and will be available to you upon request.
If you received this Notice on our Web site or by email, you are entitled to receive this Notice in written form.

Questions and Complaints

• If you want more information about our privacy practices or have questions or concerns, please contact us.

• If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alterative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

• We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:         Cindy Payne
Telephone:                  (419) 289-1430
Fax:                           (419) 289-1437
E-mail:                     info@ACOHS.org
Address:                   9th Street Dental Center
                                 431 East 9th Street
                                 Ashland, OH  44805

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