4975 Bradenton Avenue
Dublin, Ohio 43017
Phone: 614.766.0773
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Notice of Privacy Practices


We are required by law to maintain the privacy of your medical information (also known as "protected health information"). In other words, we must make sure that medical information that identifies you is kept private. We are committed to protecting your privacy rights, and will only use or disclose your medical information as permitted by law.

This is a formal notice, as required by law, explaining how we may use and disclose your PROTECTED HEATLH INFORMATION (or "PHI"). It also describes your rights to access and control PHI. If you have any questions about this Notice, how we use or disclose your PHI, or any of your rights, please contact our Privacy Officer, as identified below.



FOR TREATMENT - We may use PHI to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technologists, medical students or other people who are taking care of you. We may also share medical information with other health care providers to assist them in treating you.

FOR PAYMENT - We may use and disclose PHI for payment purposes. If an insurance company requests a copy in writing of your medical records in order to process or pay a claim, a copy only relevant to that date of service will be provided to your carrier.

FOR HEALTH CARE OPERATIONS - We may use and disclose your medical information for our health care operations. This may include measuring and improving quality, evaluation of personnel, conducting training programs, facility accreditation, certificates, licenses and other credentials we need to fully serve you.

APPOINTMENTS AND SERVICES - We may contact you (and provide as little PHI as possible) as a reminder that you or the patient has an appointment. We may also contact you with test results. You have the right to request that we contact you at a different location or in a different way than you listed on the registration form you completed in the past. You must request this in writing, either by designating alternatives on the registration form, or by form completion.

BUSINESS ASSOCIATES - We will share your PHI with third party 'business associates' that perform various activities (e.g., billing, transcription) for our office. Whenever an arrangement between us and a business associate involves the use or disclosure of PHI, we will have a written contract that contains terms that will protect the privacy of this PHI.

OTHERS INVOLVED IN YOUR HEALTHCARE - Unless you object, we may disclose, to a member of your or the patient's family, relative, or close friend or any other person you identify, PHI that directly relates to that person's involvement in the patient's health care. If you are unable to agree or object to such a disclosure (for example, in an emergency situation or if the patient is incapacitated), we may disclose such information as necessary if we determine that is in the patient's best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for the patient or the patient's location, and general condition.



AS REQUIRED BY LAW - We may disclose PHI when required to do so by federal, state or local law. If required by law, you will be notified of such disclosures. Some areas that require release include gun shot or stab wounds, domestic violence, and victims of abuse and neglect.

PUBLIC HEALTH - We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability, or report births, deaths, non-accidental physical injuries, reactions to medications (for example, in cooperation with the FDA) or problems with products.

HEALTH OVERSIGHT - We may disclose PHI to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil right laws.

LEGAL PROCEEDINGS - We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court, subpoena, discovery request of other lawful process, subject to all applicable legal requirements.

LAW ENFORCEMENT - We may release PHI if asked to do so by a law enforcement official in response to a supoena, warrant, summons or smilar process, subject to all applicable legal requirements. This may include limited information requests for identification and location purposes, information pertaining to victims of crime, suspicion that death has occured as a result of criminal conduct, in the event that a crime occurs on our premises, or regarding a medical emergency (not on our premises) where it is likely that a crime has occured.

CORONERS MEDICAL EXAMINERS AND FUNERAL DIRECTORS - We may disclose PHI for identification purposes, determining cause of death or for these persons to perform their duties as authorized by law.

CRIMINAL ACTIVITY - We may disclose PHI, if permitted by federal and state laws, if we believe that this information is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identity or apprehend an individual.

MILITARY VETERANS NATIONAL SECURITY AND INTELLIGENCE - We may disclose PHI of individuals who are or were Armed Forces, national security or intelligence personnel if requested by military command or other government authorities for the purposes of determination of eligibility for benefits, for activities deemed necessary by appropriate military command, or for conducting national security and intelligence activities (protection of the President or other legally authorized to receive protection). We may also disclose PHI to foreign military authorities if you are a member of that foreign military service.

WORKER'S COMPENSATION - We may disclose PHI as authorized to comply with worker's compensation laws and other similar legally established programs.

INMATES - We may disclose PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.

RESEARCH - We may use or disclose PHI 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 this PHI.


3. USES OF YOUR PHI WHICH REQUIRE YOUR AUTHORIZATION. Except as set forth in Section 1 or 2, above, other uses and disclosures of PHI will be made only with your written authorization. For example, although we are unlikely to ever do so, if we share your health care information for marketing purposes or if your health care information includes psychotherapy notes, we must get your written authorization before using or disclosing such information. If you choose to authorize use or disclosure, you can later revoke that Authorization by notifying us in writing of your decision.


4. YOUR INDIVIDUAL RIGHTS. The following is a statement of your rights with respect to your PHI.

You Have A Right To:

a) Inspect and copy your PHI. You may inspect and obtain a copy of PHI about you or your child. All requests must be in writing and signed by the patient or his parent or legal guardian if a minor. We will charge $2.00 per page (with a $15.00 minimum) for copies and postage, if mailed. However, under federal law, you may not have a right to inspect or copy certain types of PHI. In some cases, you may have a right to a review of our decision to deny you access to such PHI.

b) Receive an accounting of certain disclosures we have made. This right applies to disclosures for purposes other than treatment, payment and healthcare operations. You have the right to receive specific information regarding those disclosures that occured after April 14, 2003. You must submit this request in writing. We may charge you for the costs of providing the list.

c) Request limits on the use or disclosure of your PHI. You may ask us not to use or disclose a part of PHI for the purposes of treatment, payment or healthcare operations. You may also ask that PHI not be disclosed to family members or friends who may be involved in your care or the payment for it. Your request must state the specific restriction requested and to whom you want the restriction to apply. In most cases, we are not required to agree to a restriction that you may request. The one exception is that, under new rules, if you pay entirely for a service "out of pocket", we must honor your request to not share information about that service with your insurance company or other payer. If we agree to the requested restriction, we may not use PHI in violation of that restriction unless it is needed to provide emergency treatment.

d) Request to receive confidential communications from us by different means or at a different location. Any request must be made in writing. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will accomodate reasonable requests and not ask an explanation from you as to the basis for the request.

e) Request amendments to your PHI. If you believe PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. You must complete and submit a Medical Record Amendment/Correction Form. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • we did not create
  • is not part of the health information that we keep
  • you would not be permitted to inspect and copy under federal law
  • we believe is accurate and complete

f) Obtain a paper copy of this notice from us upon request, at any time.

g) Be notified following a breach of your unsecured PHI.


5. CHANGES TO THIS NOTICE: We reserve the right to modify or change this Notice at any time, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. Revision to the Notice will be available on request by contacting the office. An updated Notice will be posted in the office and our website as soon as after the revision.



If you have any questions about this Notice or your privacy rights, please contact us:

Ohio Sleep Medicine Institute
Attention: Privacy Officer
4975 Bradenton Avenue
Dublin, OH 43017

If you believe your privacy rights have been violated, you can file a written complaint with our office by contacting our Privacy Officer. You may also file a complaint with the Government ( the Office of Civil Rights of the Department of Health and Human Services) in via its website "portal" address which is: https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf. You can also send your complaint by mail; the mailing address is:

Office of Civil Rights

Regional Manager

Department of Health/Human Services

233 N. Michigan Ave, Ste 240

Chicago, Illinois 60601

(312) 886-1807

There will be no retaliation for filing a complaint.

This amended Notice is effective as of December 1, 2015.


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