Confidentiality Agreement



This is a formal notice, as required by law, explaining how Foot and Ankle Physicians of Ohio (the “practice” or we”) may use and disclose PROTECTED HEALTH INFORMATION to carry out treatment, payment, or health care operations, and for other purposes permitted by law. It also describes your right to access and control PROTECTED HEALTH INFORMATION. We are required to abide by the terms of the Notice applies to the records of your care generated and maintained at a Practice location.

PROTECTED HEALTH INFORMATION, hereafter noted as PHI, is information about you or a patient for whom you are responsible, including demographic information, that may individually identify you or the patient, and that relates to past, present, or future health conditions and related health care services.


The following categories describe different ways that we may use and disclose your PHI. These are examples and, therefore, not every permitted use and disclosure is listed.

FOR TREATMENT. We will use PHI to provide, coordinate or manage health care and any related services. This includes communication with other physicians, nurses, technicians, support staff, or providers of services (specialists, laboratories, orthotists, prosthesis’s, facilities, pharmacies, etc.) who provide care or services requested by your physician. For example, your doctor or doctor’s staff may provide medical information to other health care providers to coordinate your care, or share information with a technician before a brace fitting or test.

FOR PAYMENT. We will use PHI to obtain payment, for treatment and services you receive and are prescribed, from you, an insurance company or a third party. This may include pre-treatment reviews or authorizations, determinations of eligibility and coverage, reviewing services providing to you for medical necessity, and insurance utilization activities. For example, we may contact your insurance company before surgery or testing to determine the need for precertification or to determine whether your plan will cover the services.

HEALTH CARE OPERATIONS. We may use or disclose PHI in order to support our business activities. These include, but are not limited to, professional peer review, employee review activities, clinical improvement, training or education of students or residents, continuation of medical education, accrediting, insurance and licensing activities and conducting or arranging for other business activities. For example, we may share your PHI with medical residents that see our patients, or we will call the patients name in the waiting room when the physician is ready to see them.

SPECIAL NOTICES. We may use your PHI, as necessary to contact you to remind you of your appointment. With your permission, we may contact you by phone to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care.

APPOINTMENTS AND SERVICES. We may contact you as a reminder that you or the patient has an appointment for treatments or medical care. We may also contact you with test results. You have the right to request and we will attempt to accommodate reasonable request by you to receive communications regarding your PHI from us by alternative means or at alternative locations. For example if you wish reminders or results not be left on voicemail or sent to a particular address, we will attempt to accommodate reasonable request. You must request this in writing, by designating alternatives on the registration form.

BUSINESS ASSOCIATES. We will share your PHI with third party ‘business associates’ that perform various activities (e.g. billing, transcription). 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 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 it 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 of the patient’s location, and general condition.

COMMUNICATION BARRIERS. We may use and disclose you or your child’s PHI if your physician or another physician attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgement that you intended to consent to use or disclose under the circumstances.

EMERGENCIES. Consent is not required before using or disclosing PHI in an emergency treatment situation. We will attempt to obtain consent, but will proceed with treatment and use and disclosure of PHI as needed. If this happens, your physician will try to obtain your consent as soon as reasonable possible.

IMMUNIZATIONS. We will disclose proof of immunization to a school where the state or other similar law requires it prior to admitting a student, if we obtain agreement (which can be oral) from the student (if an adult or emancipated minor), parent or legal guardian of the student.

OTHER USES OF PHI WITH CONSENT. Other uses and disclosures of your medical information not covered by this Notice or required by the laws that apply to the Practice, will be made only with your written permission (your written permission is referred to as an Authorization). If you provide your permission to use or disclose medical information about you, you may revoke that permission; we will no longer use or disclose medical information about you for the reasons indicated in your written Authorization. You understand that we are unable to take back any disclosures that we made before we received your written notice revoking your Authorization. The following uses and disclosures will be made only your authorization: (i) most uses and disclosures of psychotherapy notes (if maintained by us); (ii) uses and disclosures for marketing; (iii) uses and disclosures for research (unless appropriate board approval of a waiver of authorization has been obtained) and (iv) disclosures that constitute a sale of PHI.

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 rights 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 or 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 subpoena, warrant, summons or similar process, subject to all applicable legal requirements. This may include limited information request for identification and location purposes, information pertaining to victims of crime, suspicion that death has occurred as a results 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 occurred.

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 identify 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 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 others 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 without your authorization 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.

HEALTH INFORMATION EXCHANGE. We participate in Health Information Exchange (HIE). The HIE is a secure computer network that connects electronic health record systems used by different health care providers and facilities in Ohio. The exchange allows participating providers online access to patient data across multiple care settings for a better picture of your health needs. You are automatically enrolled in the HIE, but can opt-out at any time. To opt-out, you will need to complete the Request to change Consent form, which is available at each office or on our website at You may submit the form using one of the following options:

*Hand deliver to Foot and Ankle Physicians of Ohio office.
*Mail to Dr. Elizabeth Hewitt’s office, Attn: HIE Consent Status
*Have a notary public witness your signature and mail it to Foot and Ankle Physicians of Ohio.


You have the right to inspect and copy your PHI. You may inspect and obtain a copy of PHI about you. All request must be in writing and signed by the patient or his/er authorized representative (e.g. parent or legal guardian). We will charge for all copies and postage, if mailed. However, under federal law, you may not have a right to inspect or copy certain types of PHI, such as information that will be used in a civil, criminal or administrative action or proceeding. In some cases, you may have a right to a review of our decision to deny you access to such PHI. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the same person who denied your request. We will comply with the outcome of the review. To inspect or obtain a copy of your medical information, you must submit your request in writing to the Site Manager at the location where you were treated.

You have the right to request limits on the use and disclosure of PHI. You may ask us not to use or disclose any part of the 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. You may restrict disclosure to a health plan concerning treatment or health care operation for which you have paid out of pocket in full. Your request must be in writing and cannot apply to releases done prior to the date of signature. Your request must states the specific restriction requested and to whom you want the restriction to apply. The Practice is not required to agree to a restrictions that may request except for request to restrict certain disclosures to health plans, as described above in this section. If the physician at the Practice believes it is in your or the patients best interest to permit use of PHI. The PHI use will not be restricted. If the Practice agrees to the requested restriction, we may not use PHI in violation of that restriction unless it is needed to provide emergency treatment.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. 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 accommodate reasonable request. We will not request an explanation from you as to the basis for the request. This request must be made in writing.

You may have the right to amend 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 Practice. You must complete and submit a Medical Record Amendment Request form to the location where you were treated to the attention of the Site Manager. 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, unless the person or entity that created the information is no longer available to make the amendment
*is not part of the health information that we keep
*you would not be permitted to inspect and copy under federal law
*is accurate and complete

You have the right to 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 occurred after October 20th 2017. You must submit this request in writing to the location where you were treated to the attention of the Site Manager. The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the cost of providing the list.
You have the right to obtain a paper copy of this Notice from us, upon request, at any time. You may also obtain a copy of this Notice at our website at

You have the right to be notified following a breach of your unsecured PHI. 


This practice reserves the right to modify or change this Notice at any time, and to make the revised or changed notice effective for PHI that we maintain. Revision o the Notice will be available on request on or after the effective date of the revision by contacting us. An updated Privacy Notice will also be posted at our location.

If you believe your privacy rights have been violated, you can submit a writing complaint to:

Foot and Ankle Physicians of Ohio
3387 Farm Bank Way
Grove City, Ohio 43123


After only 3 months after seeing Dr. Hewitt, I’m happy to report my heel pain is gone! I’m back to golfing and can stand all day without pain at work! I wish I had gone to see Dr. Hewitt sooner. I can’t believe I had lived years with the discomfort of plantar fasciitis.
- Wesley