Health Information Release
How do I get access to my medical records?
In order to receive copies of your medical record or to send copies of your medical record to others, you will first need to complete the appropriate release of health information form.
- Complete all the fields on the form when requesting the release of your records.
- If mailing or faxing in the form, make sure you include a copy of your driver's license in order for us to verify your identity.
- Make sure the form(s) are signed and dated.
Processing time varies depending on volume and availability of the medical record. To reduce copy charges, you may request recent information or specific documents, in lieu of the complete medical record.
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003 Revised Date: September 26, 2019
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW THIS NOTICE
Aultman provides health care to our patients in a clinically integrated health care setting. The privacy practices described in this Notice will be followed by the members of this clinically integrated health care team, which includes all the health care professionals, employees, medical staff, trainees, students, volunteers, and business associates of the Aultman.
Aultman organizations that will follow this Notice include all of our hospitals, employed physicians, doctor offices, entities, foundations, facilities, home care programs, and other services. These organizations are listed on our website, www.aultman.org/patientprivacy, or may be obtained by calling the Aultman Privacy Office at 330-363-3380.
OUR PLEDGE TO YOU
We understand that health information about you is personal. Aultman is committed to protecting your health information. This Notice applies to all of the health records that identify you and the care you receive at Aultman facilities. We are legally required to maintain the privacy of our patients’ health information, provide you with a copy of this Notice, and follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The members of Aultman’s clinically integrated health care team may share your health information with each other for reasons of treatment, payment, and health care operations. Sharing this information makes it possible for Aultman to care for you thoroughly and efficiently. Everyone at Aultman is required to protect your health information.
Your Authorization: Except as outlined in the following pages, we will not use or disclose your health information for any reason unless you have signed a form authorizing us to do so. You have the right to cancel your authorization in writing unless we have taken any action in reliance on the authorization.
Uses and Disclosures for Treatment: We will use and disclose your health information as needed for your treatment. For example, doctors and nurses and other professionals involved in your care will use information in your medical record, and/or information that you give them, in order to treat you. We may also disclose your health information to another health care facility or professional who is not affiliated with Aultman but who is or may be providing treatment to you. For instance, if you are going to receive home care after you leave the hospital, we may release your health information to that home health care agency so that they can treat you.
Uses and Disclosures for Payment: We will use and disclose your health information for the purpose of allowing us, as well as other entities, to secure payment for the health care services provided to you. For example, we may forward information regarding your medical treatment to your health plan to arrange payment for the services provided to you. We also may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your health plan will cover the treatment.
Uses and Disclosures for Health Care Operations: We will use and disclose your health information as needed, and as permitted by law, in the process of our daily operations. These operations may include, but are not limited to: clinical improvement, professional peer review, business management, accreditation, and licensing. For example, we may use and disclose your health information for purposes of improving the clinical treatment and care of our patients or to determine the needs and preferences of our patients. We may also disclose your health information to another health care facility, health care professional or other covered entity for such things as quality assurance and case management, but only if they have or had a patient relationship with you.
Our Hospitals’ Patient Directory: In our hospital settings, Aultman will list your name, location, general condition and, if you wish, your religious membership in the Patient Directory. Unless you choose to be excluded from this directory, your information, not including religious membership, will be given to anyone who asks for you by name. This information, including your religious membership, may also be provided to members of the clergy. You have the right to request that your information be excluded from this directory.
Family and Friends Involved in Your Care: With your approval, we may disclose your health information to designated family, friends and others who are involved in your care or in payment of your care. If you are unable to give approval or facing an emergency situation, we may then share parts of your health information with such individuals without your approval in order to treat you. We may also disclose limited health information to an entity that is authorized to assist in disaster relief efforts, so your family can be notified of your condition, status and location.
Business Associates: Certain aspects and components of our health care operations such as auditing, accreditation, legal services, etc. may be performed through contracts with outside persons or organizations. At times, we may need to provide some of your health information to these outside persons or organizations. In all cases, we require these business associates to protect the privacy of your information.
Appointments and Services: We may contact you with reminders or test results. You may request that we provide this information by another means or at another location. For example, if you do not want appointment reminders left on voice mail or sent to a certain address, we will make every effort to accommodate reasonable requests. Please make this request in writing to the medical records department of the Aultman facility where you received services.
Health Information Exchanges: We may participate in health information exchanges that facilitate the secure exchange of your electronic health information between and among several health care providers or other health care entities for your treatment, payment, and/or other health care operations purposes. This means we may share information we obtain or create about you with outside entities (such as hospitals, doctors’ offices, pharmacies, or health plans). Or we may receive information they create or obtain about you (such as medication history, medical history, treatment notes, or insurance information) so each of us can provide better, safer treatment, and coordinate your health care services.
Research: In limited cases, we may use or disclose your health information for research purposes. For example, a research organization may wish to compare all patients who received a certain drug and will thus need to review medical records. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements. These requirements are applied by an Institutional Review Board that oversees the research or by representations of the researchers that will limit their use and disclosure of patient information.
Marketing: We must receive your authorization for any use or disclosure of your health information for marketing – unless the communication is made directly to you in person, is a promotional gift of nominal value, is a prescription refill reminder, is general health or wellness information, or a communication about health related products or services we offer or that are directly related to your treatment.
Sales of Health Information: We must receive your authorization for any sale of your health information unless for treatment or payment purposes or as required by law.
Psychotherapy Notes: We must receive your authorization for any use or disclosure of psychotherapy notes unless the use or disclosure is otherwise permitted or required by law.
Fundraising Activities: We may contact you to donate to a fundraising effort for or on our behalf. We may disclose your health information to a foundation related to Aultman, so that they may contact you. You have the right to “opt out” of receiving fundraising materials or communications by submitting your name and address to The Aultman Foundation, 2600 Sixth St. S.W., Canton, Ohio 44710 in writing with a statement that you do not wish to receive fundraising materials or communications from us.
Incidental Disclosures: Although we take reasonable measures to ensure your privacy, certain disclosures of your health information may occur incidentally. For example, other patients may see your name on a sign-in sheet, or you may overhear a physician’s confidential conversation with another provider or patient.
Teaching: Aultman uses many of its facilities to provide educational opportunities to residents, fellows and students in medicine, nursing, radiology, pharmacy, allied health and other studies. These individuals may be assisting with your care under the supervision of a licensed health care provider as a part of their professional health care training program.
Organ and Tissue Donation: As necessary, we may use or disclose your health information to organizations that arrange organ donations, eye or tissue procurements, transplants, or donations to an organ donation bank.
Other Uses or Disclosures of Information: We are permitted or required by law to make certain other uses and disclosures of your health information without your consent or authorization as follows:
- For any purpose required by law.
- For public health activities such as required reporting of disease, injury, birth, and death; and for public health investigations.
- If we suspect child abuse or neglect, or if we think you are a victim of abuse, neglect or domestic violence.
- To release immunization records 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 or 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.
- To government agencies conducting audits, investigations or civil or criminal proceedings.
- If required to do so by subpoena or discovery request; in some cases you will have notice of such release.
- To law enforcement officials as required by law or to report wounds or injuries and crimes.
- To coroners and funeral directors consistent with the law.
- If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may release information about you to the correctional institution as authorized or required by law.
- In limited instances, if we suspect a serious threat to health or safety.
- If you are a member of the military, as required by armed forces services; we may also release your health information, if necessary, for national security or intelligence activities.
- To workers’ compensation agencies, if necessary, for your workers’ compensation benefit determination.
- As required by Ohio Ohio law requires that we obtain a consent from you in many instances before disclosing the performance or results of an HIV test or diagnosis 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; before disclosing information about mental health services you may have received; and before disclosing information to the State Long-Term Care Ombudsman. For more information on when such consents may be necessary, you can contact the Compliance Department listed at the end of this notice.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Right to Inspect and Copy: You have the right to request a copy and/or inspect much of the health information that we keep on your behalf. All requests to inspect or copy must be made in writing and signed by you or your representative. If you request copies, you will be charged our regular fees for copying and mailing the requested information. You may obtain an authorization request form and a fee schedule from the medical records department of the Aultman facility where you received services.
Right to Electronic Copies: You have the right to obtain an electronic copy of your health information that we keep on your behalf and that exists in an electronic format. You may direct that the copy be transmitted directly to an entity or person designated to 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.
Right to Amend: You have the right to request in writing that the health information we maintain about you be amended or corrected. We are not required to make all the changes or corrections you request. However, we will give each request careful consideration. All requests must be in writing, be signed by you or your representative, and must state the reasons for the amendment or correction. If an 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. You may obtain an amendment request form from the medical records department of the Aultman facility where you received services.
Right to an Accounting of Disclosures: You have the right to an accounting of certain disclosures we have made of your health information. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free; you will be charged our regular fees for each subsequent accounting you request within the same 12-month period. You may obtain an accounting request form and a fee schedule from the medical records department of the Aultman facility where you received services.
Right to Request Individual Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information for treatment, payment or health care operations. In most cases, we are not required to agree to your restriction request but will attempt to accommodate reasonable requests as appropriate, and we may terminate an agreed-to restriction if we believe such termination is appropriate. We will tell you if we agree with your request or not. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. We will notify you if we terminate a requested restriction. 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 Aultman has been paid in full. You may obtain a restriction request form from the medical records department of the Aultman facility where you received services.
Breach Notification: In the unlikely event that there is a breach, or unauthorized release of your personal health information, you will receive notice and information on steps you may take to protect yourself from harm.
Changes to This Notice: 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 health information maintained by us. You may obtain a copy of the current notice from the Aultman facility where you received services, from www.aultman.org, or by mailing a request to the Aultman Compliance Department listed below.
Complaints: If you believe your privacy rights have been violated, you may file a complaint in writing to: Aultman Compliance Department, 2600 Sixth St. S.W., Canton, Ohio 44710; by phone at 330-363-3380; or by email at email@example.com. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. There will be no retribution for filing a complaint.
Acknowledgement of Receipt of Notice: You will be asked to sign a form that you received this Notice of Privacy Practices.
For Further Information About This Notice, Contact: Aultman Compliance Department, 2600 Sixth St. S.W., Canton, Ohio 44710; 330-363-3380; firstname.lastname@example.org.
You have the right to obtain a paper copy of this notice upon request, even if you have requested such a copy by email or other electronic means. Paper copies may be obtained from any Aultman facility or from the Aultman Compliance Department listed above. This notice is also available at www.aultman.org.