Notice of Privacy Practices


I. Who We Are

This Notice describes the privacy practices of CG Medical Associates. It applies to the health services you receive at the below entities:

  1. CG Medical Associates: including its nurses, residents, other staff, and volunteers;
  2. Portions of CG Medical Associates that support the activities of health care including its physicians, nurses, students, volunteers, and other staff.

Collectively, the BCU and these portions of CG Medical Associates will be referred to as "we" or "us". We will share your health information among ourselves to carry out our treatment, payment, and health care operations.

II. Our Privacy Obligations

The law requires us to maintain the privacy of certain health information called "Protected Health Information" ("PHI"). Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice.

III. Ways We Can Use and Share Your PHI without Your Written Permission (Authorization)

In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe in Section IV below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:

A. Uses and Disclosures for Treatment, Payment and Health Care Operations. We may use and share your PHI to provide "Treatment," obtain "Payment" for your Treatment, and perform our "Health Care Operations." These three terms are defined as:

  • Treatment. We use and share your PHI to provide care and other services to you—for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care.
  • Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request payment and receive payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care ("Your Payor") and to confirm that Your Payor will pay for health care. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
  • Health Care Operations. We may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. As another example, we may share PHI with our Patient Relations Coordinator to resolve any complaints you may have and make sure that you have a comfortable visit with us.

In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.

B. Your Other Health Care Providers. We may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.

C. Disclosure to Relatives, Close Friends and Your Other Caregivers. We may share your PHI with your family member/relative, a close personal friend, or another person who you identify if we (1) first provide you with the chance to object to the disclosure and you do not object; (2) infer that you do not object to the disclosure; or (3) obtain your agreement to share your PHI with these individuals. If you are not present at the time we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, we may use our professional judgment to decide that sharing the PHI is in your best interest. We may also use or share your PHI to notify (or assist in notifying) these individuals about your location and general condition.

D. Public Health Activities. We are required or are permitted by law to report PHI to certain government agencies and others. For example, we may share your PHI for the following:

  1. to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability;
  2. to report abuse and neglect to the Ohio Department of Children and Family Services, the Ohio Department of Human Services, or other government authorities, including a social service or protective services agency, that are legally permitted to receive the reports;
  3. to report information about products and services to the U.S. Food and Drug Administration;
  4. to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of developing or spreading a disease or condition;
  5. to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and
  6. to prevent or lessen a serious and imminent threat to a person for the public's health or safety, or to certain government agencies with special functions such as the State Department.

E. Health Oversight Activities. We may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicare or Medicaid, are being followed.

F. Judicial and Administrative Proceedings. We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

G. Law Enforcement Purposes. We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.

H. Decedents. We may share PHI with a coroner or medical examiner as authorized by law.

I. Organ and Tissue Procurement. We may share your PHI with organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.

J. Workers' Compensation. We may share your PHI as permitted by or required by state law relating to workers' compensation or other similar programs.

K. As required by law. We may use and share your PHI when required to do so by any other law not already referred to above.

IV. Uses and Disclosures Requiring Your Written Permission (Authorization)

A. Use or Disclosure with Your Permission (Authorization). For any purpose other than the ones described above in Section III, we may only use or share your PHI when you grant us your written permission (authorization). For example, you will need to give us your permission before we send your PHI to your life insurance company.

B. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including any portion of your PHI that is: (1) kept in psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, Treatment and referral; (4) about HIV/AIDS testing, diagnosis or Treatment; (5) about sexually transmitted disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) Invitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.

V. Your Rights Regarding Your Protected Health Information

A. For Further Information; Complaints. If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our HIPAA Officer. You may also file written complaints with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, the HIPAA Officer will provide you with the correct address for the OCR. We will not take any action against you if you file a complaint with us or with the OCR.

B. Right to Receive Confidential Communications. You may ask us to send papers that contain your PHI to a different location than the address that you gave us, or in a special way. You will need to ask us in writing. We will try to grant your request if we feel it is reasonable. For example, you may ask us to send a copy of your medical records to a different address than your home address.

C. Right to Revoke Your Written Permission (Authorization). You may change your mind about your authorization or any written permission regarding your PHI by giving or sending a written "revocation statement" to the HIPAA Officer at the address below. The revocation will not apply to the extent that we have already taken action where we relied on your permission.

D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. You can review these records and/or ask for copies. Under limited circumstances, we may deny you access to a portion of your records. If you want to access your records, you may obtain a record request form from our office. Return the completed form to our office. If you request copies, we will charge you the amount listed on the rate sheet. We will also charge you for our postage costs, if you request that we mail the copies to you. For a copy of records, material, or information that cannot routinely be copied on a standard photocopy machine, such as x-ray films or pictures, we may charge for the reasonable cost of the copy.

E. Right to Amend Your Records. You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. If you want to amend your records, you may obtain an amendment request form from the HIPAA Officer. After which, you can return the completed form to the HIPAA Officer. We will comply with your request unless we believe that the information that would be amended is correct and complete or that other circumstances apply. In the case of a requested amendment concerning information about the Treatment of a mental illness or developmental disability, you have the right to appeal to a state court our decision not to amend your PHI.

F. Right to Receive an Accounting of Disclosures. You may ask for an accounting of certain disclosures of your PHI made by us on or after April 14, 2003. These disclosures must have occurred before the time of your request, and we will not go back more than six (6) years before the date of your request. If you request an accounting more than once during a twelve (12) month period, we will charge you based on the rate sheet. Direct your request for an accounting to the HIPAA Officer.

G. Right to Request Restrictions. You have the right to ask us to restrict or limit the PHI we use or disclose about you for treatment, payment, or health care operations. With one exception, we are not required to agree to your request. If we do agree, we will comply unless the information is needed to provide emergency treatment. Your request for restrictions must be made in writing and submitted to the HIPAA Officer at the address below. We must grant your request to a restriction on disclosure of your PHI to a health plan if you have paid for the health care item in full out of pocket.

H. Right to Receive Paper Copy of this Notice. If you ask, you may obtain a paper copy of this Notice, even if you have agreed to receive the notice electronically.

VI. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective as of October 19, 2011.

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in common areas throughout our clinic. You also may obtain any new notice by contacting the HIPAA Officer.

VII. HIPAA Officer

You may contact the HIPAA Officer at
7300 Beechmont Avenue
Cincinnati, OH 45230
Telephone Number: (513) 232-9100
Fax Number: (513) 232-3333