Privacy Notice

ICP is required by law to maintain the privacy of your health information. ICP is also required to provide you with a notice that describes ICP’s legal duties and privacy practices and your privacy rights with respect to your health information. We will follow the privacy practices described in this notice. If you have any questions about any part of this Notice or if you want more information about the privacy practices of ICP, please contact:

Martha Somers,
HIPAA Compliance Officer
1815 W. County Road 54
Tiffin, OH 44883

We reserve the right to change the privacy practices described in this notice in the event that the practices need to be changed to be in compliance with the law.  We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. It will also be posted at the location of service.

How ICP May Use or Disclose Your Health Information for Treatment, Payment of Health Care Operations

The following categories describe the ways that ICP may use and disclose your health information. For each type of use and disclosure, we will explain what we mean and present some examples.  Treatment.  We may use or disclose your health care information in the provision, coordination or management of your health care. Our communications to you may be by telephone, cell phone, e-mail, patient portal, or by mail.  If another provider requests your health information and they are not providing care and treatment to you we will request an authorization from you before providing your information. All e-mail containing your health information is accompanied by a confidentiality notice, encrypted and password protected. Payment.  We may use or disclose your health care information to obtain payment for your health care services. For example, we may use your information to send a bill for your health care services to your insurer. Health Care Operations.  We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning and compliance with the law. For example, we may use your information to determine the effectiveness of the care and services you are receiving. If the activities require disclosure outside of our health care organization, we will request your authorization before disclosing that information.

How ICP May Use or Disclose Your Health Information Without Your Written Authorization

The following categories describe the ways that ICP may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and present some examples.

  • Required by Law.  We may use and disclose your health information when that use or disclosure is required by law. For example, we may disclose medical information to respond to a court order.
  • Public Health.  We may release your health information to local, state or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases and reporting problems with products and reactions to medications to the Food and Drug Administration.
  • Victims of Abuse, Neglect or Violence.  We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect or violence relating to children or the elderly.
  • Health Oversight Activities.  We may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure and other proceedings related to oversight of the health care system.
  • Judicial and Administrative Proceedings.  We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order. Under most circumstances when the request is made through a subpoena, a discovery request or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
  • Law Enforcement.  We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes.  Under some limited circumstances we will request your authorization prior to permitting disclosure.
  • Coroners and Medical Examiners.  We may disclose your health information to coroners and medical examiners.  For example, this may be necessary to determine the cause of death.
  • Research.  Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to cure a heart disease or whether a certain treatment is working better than another.
  • To Avert a Serious Threat to Health of Safety.  We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public.  Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
  • Specialized Government Functions. Under certain and very limited circumstances, we may disclose your health care information for military, national security, or law enforcement custodial situations.
  • Workers’ Compensation.  Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization.  These programs may provide benefits for work-related injuries or illness.
  • Health Information.  We may use or disclose your health information to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you.
  • Others Involved in Your Health Care.  We may disclose your protected health information to a friend or family member that is involved in your health care. We also may disclose your information to an entity assisting in a disaster relief effort so at your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your protected health information, then, using professional judgment, we may determine whether the disclosure is in your best interest.

When ICP is Required to Obtain an Authorization to Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing and the sale of protected health information require your authorization. If your provider intends to engage in fundraising, you have the right to opt out of receiving such communications.  If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

  • Your Health Information Rights Inspect and Copy Your Health Information.  You have the right to inspect and obtain a copy of your health care information. You have the right to request that the copy be provided in hard copy or electronic format (e.g., fax copy, PDF emailed or saved to CD).  If the form and format are not readily producible, then the organization will work with you to provide it in a reasonable electronic form or format. For example, you may request a copy of your medication records from your health care provider.  Your request for inspection or access must be submitted in writing to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883. In addition, we may charge you a reasonable fee to cover our expenses for copying your health information.
  • Request To Correct Your Health Information.  You have a right to request that ICP amend your health information that you believe is incorrect or incomplete.  If you believe information you receive is incorrect; you may request that the information be corrected. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must make your request in writing to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883.  You must also provide a reason for your request.
  • Request Restrictions on Certain Uses and Disclosures.  You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities.  For example, if you are an employee in a clinic and you receive health care services in that clinic, you may request that your medical record not be stored with the other clinic records.  However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a disclosure restricted to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you, or the person other than the health plan on your behalf, has paid the covered entity in full.  If you would like to make a request for restrictions, you must submit your request in writing to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883.
  • Receive Confidential Communications Of Health Information.  You have the right to request that we communicate your health information to you in different ways or places.  For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address.  We must accommodate reasonable requests.  To request confidential communications, you must submit your request in writing to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883.
  • Receive A Record Of Disclosures Of Your Health Information.  You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law.  This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made.  For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made. For example, you may request a list that indicates all the disclosures your health care provider has made from your health care record in the past six months.  To request this accounting of disclosures, you must submit your request in writing to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883.  We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.
  • Obtain A Paper Copy Of This Notice.  Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically.  To obtain a paper copy of this Notice, send your written request to: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883.  ICP maintains a web site that provides information about our company and our services.  The Privacy Notice is posted on the website and is available in electronic format for viewing and printing.
  • Notified of a Breach.  Your provider is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.
  • Complaint.  If you believe your privacy rights have been violated, you may file a complaint with: Martha Somers, HIPAA Compliance Officer, 1815 W. County Road 54, Tiffin, OH 44883 who will provide you with any needed assistance.  We request that you file your complaint in writing so that we may better assist in the investigation of your complaint.  You may also file a complaint with the Secretary of the Department of Health and Human Services.  If your complaint relates to your privacy rights while you were receiving treatment for mental illness, alcohol or drug abuse or a developmental disability you may also file a complaint with the staff or administrator of the treatment facility or community mental health program.  There will be no retaliation against you in any way for filing a complaint.

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:

Martha Somers,
HIPAA Compliance Officer
1815 W. County Road 54
Tiffin, OH 44883

Effective Date of This Notice: September 23, 2013

Rev 1/23/2018
Form112

Download Printable Copy – PDF Format

Download Printable Brochure Format of Privacy Practices – pdf format

Rev 1/23/2018
Form112