Patient Privacy

Samaritan Family Care/MVHE/Premier Health Specialists/Upper Valley Professional Corporation

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 
PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices apply to the physician companies of Premier Health (Samaritan Family Care, Inc., MVHE, Inc., Premier Health Specialists, Inc., and Upper Valley Professional Corporation).  The Medical Practices of this organization will share protected health information of our patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

We are required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information.  We are required to abide by the terms of this Notice so long as it remains in effect.  We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us.  You may receive a copy of any revised notices from the Office Manager of this practice.

Uses and Disclosures of Your Protected Health Information

Your Authorization: Except as outlined below, we will not use or disclose your protected health information for any purpose unless you have signed a form authorizing the use or disclosure.  You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.  There are certain uses and disclosures of your protected health information for which we will always obtain a prior authorization, and these include:

  • Marketing communications, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, general health or wellness information, or a communication about health related products or services that we offer or that are directly related to your treatment;
  • Most sales of your protected health information unless for treatment or payment purposes or as required by law; and
  • Psychotherapy notes unless otherwise permitted or required by law.

Uses and Disclosures for Treatment: We will use and disclose your protected health information as necessary for your treatment. For instance, doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, test, etc.  We may also release your protected health information to another health care facility or professional who is not affiliated with our practice but who is or will be providing treatment to you.  For instance if, after you leave the office, you are going to receive hospital care, we may release your protected health information to that hospital so that a plan of care can be prepared for you.

Uses and Disclosures for Payment: We will use and disclose your protected health information as necessary for the payment of those health professionals and facilities that have treated you or provided services to you.  For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange a payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for payment of your bill.

Uses and Disclosures for Health Care Operations: We will use and disclose your protected health information as necessary, and as permitted by law, for our healthcare operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc.  For instance, we may use and disclose your protected health information for purposes of improving the clinical treatment and care of our patients.  We may also disclose your protected health information to another health care facility, health care professional, or health plan for such things as quality assurance and case management but only if that facility, professional, or plan also has or had a patient relationship with you.

Health Information Exchange: We may participate in health information exchanges (HIEs) to facilitate the secure exchange of your electronic health information between and among other health care providers, health plans, and health care clearinghouses that participate in the HIE.  In order to provide better treatment and coordination of your health care, we may share and receive your health information for treatment, payment, or other health care operations.  Your participation in the HIE is voluntary, and your ability to obtain treatment will not be affected if you choose not to participate.  You may opt-out at any time by notifying the Office Manager of this practice.  However, your choice to opt-out does not affect health information that was disclosed through an HIE prior to the time that you opted out.

Family and Friends Involved in Your Care: With your approval, from time to time we may disclose your protected health information to designated family, friends, and others who are involved in your care, or are involved in payment for your care, in order to facilitate that person’s involvement in caring for you or in paying for your care.  If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval.  We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc.  At times, it may be necessary for us to provide certain protected health information to one or more of these outside persons or organizations who assist us with our health care operations.  In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Appointments and Services: We may contact you to provide appointment reminders or test results.  You have the right to request, and we will accommodate reasonable requests, to receive communications regarding your protected health information from us by alternative means or at alternative locations.  For instance, if you would prefer that appointment reminders not be left on voice mail or sent to a particular address, we will accommodate all reasonable requests.  You may request such confidential communication in writing by sending your request to the Office Manager of this practice.

Health Products and Services: We may use your protected health information from time to time to communicate with you about health products and services necessary for your treatment, to advise you of new products and services we offer, and to provide general health and wellness information.

Research: In limited circumstances, we may use and disclose your protected health information for research purposes.  For example, a research organization may wish to compare outcomes of all patients that received a particular drug and will need to review a series of medical records.  In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.

Other Uses and Disclosures: We are permitted or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization.  We may release your protected health information:

  • For any purposes required by law;
  • For public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations;
  • As required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
  • To a student’s school, but only if parents or guardians (or the student if not a minor) agree either orally or in writing;
  • To the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
  • To your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer;
  • If required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
  • If required to do so by subpoena or discovery request; in most cases you will have notice of such release;
  • To law enforcement officials as required by law to report wounds, injuries, and crimes;
  • To coroners and/or funeral directors consistent with law;
  • If necessary to arrange for an organ or tissue donation from you or a transplant for you;
  • If, in limited instances, we suspect a serious threat to health and safety;
  • As required by armed forces services if you are a member of the military; we may also release your protected health information if necessary for national security or intelligence activities; and
  • To workers’ compensation agencies if necessary for your workers’ compensation benefit determination.

Ohio law requires that we obtain a consent from you in many instances before disclosing the performance or results of an HIV test or diagnoses of AIDS or an AIDS-related condition, before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program, and before disclosing information about mental health services you may have received.  For full information on when such consents may be necessary, you can contact the Privacy Officer, 110 N. Main Street, Suite 370, Dayton, Ohio 45402.

Rights That You Have

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf.  All requests for access must be made in writing and signed by you or your representative.  We will charge you per page if you request a copy of the information.  We will also charge for the postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary.  You may obtain an Authorization for Release of Medical Information/Patient Access Form from the Office Manager of this practice.

You have the right to obtain an electronic copy of your health information that exists in an electronic format, and you may direct that the copy be transmitted directly to an entity or person designated by you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information.  We will charge you a fee for our labor and supplies in preparing your copy of the electronic health information.

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information we maintain about you be amended or corrected.  We are not obligated to make all requested amendments but will give each request careful consideration.  In order to be considered by us, all amendment requests must be submitted in writing, signed by you or your representative, and must state the reasons for the amendment/correction request.  If any amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary.

Accounting of Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures by us of your protected health information for six years prior to the date of your request.  Requests must be made in writing and signed by you or your representative.  Accounting request forms are available from the Office Manager of this practice.  The first accounting in any 12-month period is free.  You will be charged a fee for each subsequent accounting you request within the same 12-month period.

Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request, in writing, restrictions on certain of our uses and disclosures of your protected health information for treatment, payment, or health care operations.  We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate.  We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate.  In the event of a termination by us, we will notify you of such termination.  You have the right to terminate, in writing, any agreed-to restriction by sending such termination notice to the Office Manager of this practice.  We will honor any request to restrict disclosures to your health plan if the information to be disclosed pertains solely to a health care item or service for which the physician practice where you received services has been paid in full.

Breach Notification: In the unlikely event that there is a breach or unauthorized release of your protected health information, you will receive notice and information on steps you may take to protect yourself from harm.

Complaints: If you believe your privacy rights have been violated, you can file a complaint, in writing, with the Privacy Officer, 110 N. Main Street, Suite 370, Dayton, Ohio 45402.  You may also file a complaint, in writing, within 180 days of a violation of your rights with the Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601.  There will be no retaliation for filing a complaint.

Acknowledgment of Receipt of Notice: You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.

For Further Information

If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, 110 N. Main Street, Suite 370, Dayton, Ohio 45402.

As a patient, you have the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

Effective Date

This Notice of Privacy Practices is effective July 1, 2013.



Find a Provider
Search Premier HealthNet
(866) 608-FIND (3463)
Search by last name:
And/or by specialty:
More Search Options