Privacy Practices


3100 Governor’s Place Blvd. Kettering, OH 45409 (937) 297-7676


If you have any questions about this notice, please contact Kerry Chapman of our office at (937) 297-7688. This notice describes information about privacy practices followed by our employees, staff, call coverage, doctors, and other office personnel. This notice applies to the information and records we have about your health, health status, and the healthcare and services you receive or have received at this office.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you, and describes your rights and our obligations regarding the use and disclosure of that information.


For Treatment:

We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff, or other personnel who are involved in taking care of you and your health. For example, your doctor may discuss your condition with another doctor in order to coordinate your medical care. Different personnel in our office may share and disclose information about you to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering X-rays. Family members and other healthcare providers may be part of your medical care outside this office and may require information about you that we have.

For Payment:

We may use and disclose health information about you so that the treatment and services you receive at or through this office may be billed to and payment may be collected from you, an insurance company, or a third party. For example, your health insurance company may require information about your health in order to authorize and/or pay for medical services.

For Healthcare Operations/Services:

We may use your health information in order to improve the treatment and services provided at this office. For example, we may use your health information to evaluate the performance of our staff in delivering healthcare, to decide what additional services or policies we should acquire, or to contact you regarding health-related products or services that may be of interest to you.

For Appointment Reminders:

We may contact you as a reminder via phone, mail (postcard or letter), email, voicemail, etc. that you have an appointment or surgery, or that we need to reschedule an appointment or surgery for treatment or medical care provided at or through our office. If you object to any of the above policies regarding your health information please notify us in writing at the above address or by contacting Kerry Chapman at 297-7688. You may object at any time by giving us written notice and it will be effective upon receipt of such notice, but it will not apply to any uses and/or disclosures that occurred prior to that time.

If you do object to any or all of the above policies, we may not be permitted to use or disclose your health information for purposes of treatment, payment, or healthcare operations, and therefore we may choose to discontinue providing you with healthcare treatment and services.


We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety:

We may use and disclose health information about you when necessary to prevent a serious threat to the health and safety of you, another person, or the public.

Required By Law:

We will disclose health information about you when required to do so by federal, state or local law, military command, government authorities, law enforcement officials, or as a result of a court order or subpoena.


We may use and disclose health information about you IN AN ANONYMOUS MANNER (i.e. in a way that does not personally identify you) for research and educational purposes. We will always ask for written permission from you prior to using any of your health information for research purposes that may personally identify you.

Workers’ Compensation:

We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Family and Friends:

Unless specifically requested otherwise, we may deliver your health information to you and/or your family/friends by phone, answering machine, voice mail, e-mail, etc. ONLY WHEN SUCH COMMUNICATIONS ARE DEEMED IN YOUR BEST INTEREST AND ONLY UNDER THE STRICT PROFESSIONAL JUDGMENT OF THE DOCTOR OR OTHER HEALTHCARE PERSONNEL. We will always limit disclosure to information relevant to the other person’s involvement.

We will not use or disclose your health information for any purpose other than those identified above without your specific written Authorization. If you give us such Authorization, you may revoke it, in writing, at any time, and we will no longer use that information for the particular reasons stated in the Authorization thereafter. If we have HIV or substance abuse information about you, we cannot release that information without a special, signed, separate authorization from you which complies with the laws governing HIV or substance abuse records.


Right to Inspect and Copy:

You have the right to inspect and copy your health information, such as the medical and billing records, that we use to make decisions about your care. You must submit a written request to Kerry Chapman in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies.

Right to Amend:

If you believe the health information 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 at this office. We may deny your request if it is not in writing, does not include a valid reason to support the request, is not part of the health information that we keep, or if the existing information is accurate and complete.

Right to an Accounting of Disclosures:

You have the right to request an Accounting of disclosures. This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and healthcare operations. To obtain this list, submit your request in writing to Kerry Chapman stating the time period, which must be less than six years and cannot contain dates prior to April 14, 2003. You may be charged for the costs of providing the list and you will be notified of the amount prior to incurring the costs.

Right to Request Restrictions:

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to limit the information we disclose about you to a particular person. For example, you could ask that we not disclose that you recently had surgery to a family member or friend. We may not comply with the request under emergency situations.

Right to Request Confidential Communications:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only at work, home, or by mail.

Right to a Paper Copy of This Notice:

You have a right to a paper copy of this notice at any time upon request.

To exercise any of these rights or restrictions please contact Kerry Chapman at 297-7688 for the appropriate form(s). We reserve the right to change this notice and will make a current copy with the effective date available.


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Kerry Chapman at 297-7688. You will not be penalized for filing a complaint.

Effective April 14, 2003