Effective Date: April 14, 2003

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

If you have any questions about this notice, please contact Rhonda L. Melchi, Treasurer of Bowling Green Area Schools, at 419-352-3576.

Who Will Follow the Requirement of this Notice. This notice describes the District’s practices and those of its employees and business associates. The District, its employees and its business associates may share medical information with each other for the purposes of treatment, payment or other operations of the District as described in this notice.

Privacy of Health Information. We understand that medical information about you and your health is personal. This notice tells you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations that we have, regarding the use and disclosure of medical information. We are required by law to:

1. assure the medical information that identifies you is kept private.
2. give you this notice of our legal duties and privacy practices with respect to medical information about you and
3. follow the terms of the notice that is currently in effect.

Use and Disclosure of Medical Information. The following describes the different ways that we may use and disclose medical information. Generally, private health information may be released without your authorization for the purposes of treatment, payment or other healthcare operations of the District. Medical information may also be released for the following purposes:

1. as required by law;
2. for public health services;
3. in connection with the investigation of abuse, neglect or domestic violence;
4. to health oversight agencies in connection with health oversight activities;
5. for judicial and administrative proceedings;
6. for law enforcement purposes;
7. to coroners, medical examiners and funeral directors;
8. for research if a waiver of authorization has been obtained;
9. to prevent serious and imminent harm to the health or safety of a person or the public;
10. for specialized governmental functions;
11. for military and veterans activities;
12. for national security and intelligence;
13. for protective services for the President and others;
14. to the Department of the State to make medical suitability determinations;
15. to correctional institutions and law enforcement officials regarding an inmate or
16. for workers’ compensation if necessary to comply with the laws relating to workers’ compensation and other similar programs.

Rights Regarding Medical Information. You have rights regarding medical information that we maintain about you:

The only information maintained by the District about you is your health plan enrollment application and monthly premium payments made on your behalf. All claim information is maintained by the Third Party Administrator (TPA). Your rights regarding that information are contained in the TPA’s privacy notice.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. You may obtain a copy of this notice by contacting the Treasurer’s Office.

Changes to this Notice. We reserve the right to make changes to this notice and to make the revision or change applicable to medical information we already have about you. We will post a copy of the current notice in each building in the District.

Complaints. If you believe your privacy rights have been violated, you may file a complaint with the District. To file a complaint, please contact Rhonda Melchi, Treasurer, Bowling Green Area School District, Bowling Green, Ohio. (419) 352-3576.

All complaints must be submitted in writing. You can also complain to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave., S.W., Room 509F, HHH Building, Washington, D.C., 20201-0004 (800) 368-1019.

Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice will be made only with your written permission. If you provide us with permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reason covered by your written authorization. However, we will not be able to take back any disclosures that we have already made during any period in which your permission was in effect.