This notice is required by Federal Law


Why are we giving you this notice?

We at Pinewood Family Practice have always valued your privacy and the confidentiality of your personal and health care information. We have always protected that information very carefully.

The federal government became concerned that not every organization was protecting your health care information, and passed a law requiring each health care provider to follow the same set of standards. A federal law now requires that we give you this statement before we begin to treat you. We are also required to obtain another consent before we treat you, on a separate form.

Uses and disclosure:

In order to provide you with high quality health care we must collect, maintain and use information about you, including information that you probably consider confidential and private.

We use the information to treat you for your illness or condition (including referrals to specialists), to send billings on your behalf, and to facilitate health care operations in our office to insure we give you high quality health care.

Uses and specific disclosures:

Pinewood Family Practice reserves the right to use Protected Health Information without obtaining a separate patient consent:

  • To call the patient by name in the waiting room

  • To use PHI to contact the patient for appointment reminders via telephone or other means

  • To contact the patient with exam or test results

  • To provide information regarding alternate treatment

  • To contact a patient about health related benefits and services offered by the practice

We sometimes disclose your Protected Health Information to other organizations when it is helpful. This is not a complete list, but some examples would be:

  • As required by law

  • For issues of Public Health

  • For reporting of communicable diseases

  • For health oversight

  • In cases of abuse or neglect

  • To law enforcement

  • To coroners, funeral directors and organ donation

  • When required by HHS to investigate and/or determine compliance by the practice

  • To the FDA

  • For legal proceedings

  • For research

  • For military activity and national security

  • For worker’s compensation

  • When an inmate

Your individual rights:

  • You have the right to request additional restrictions on the use and disclosure of your Protected Health Information.

Please note that is usually legal for us to refuse to treat you if the restrictions prevent us from providing proper health care services.

  • You have a right to request that your Protected Health Information be communicated to an alternate location or by alternate method. For example, if you do not want information sent to your home, you have the right to have the information sent to an alternate address. You have a right to request special restrictions on your “PHI”, and we have a form for that purpose.

  • You have a right to review and to copy your Protected Health Information, with only a few exceptions. If we deny you access to your Protected Health Information, you have a right to a review of our decision by a licensed health professional.

  • You have a right to file a request for amendment of your Protected Health Information if you believe the information to be incorrect. There are rules about how you must file the amendment and how we must respond. There is a special form. We may accept or deny the amendment. The best way to request an amendment is on our Request Form, available in the office. No one can retaliate against you if you file an amendment to your information.

  • You have a right to see an accounting of every disclosure we have made of your Protected Health Information from April 14, 2003 forward.

  • You have the right to notify a healthcare provider not to tell your health insurer about services that you elect to pay out of pocket.

  • You have the right to opt out of receiving information about any fundraising conducted by a healthcare provider.

Our duties:

  • We must give you this notice before we begin treatment, except in an emergency.

    • We will obtain an acknowledgment of receipt for the Notice of Privacy Practices.

    • Obtain specific written authorization for any disclosure or use of protected health information other than for purposes of treatment, payment, or health care operations or as required by law

    • We will make reasonable efforts to preserve the confidentiality of certain communications of PHI when requested by an individual.

    • We will make copies of PHI available to you for a reasonable fee, and we will log all disclosures.

    • We must appoint a Privacy Officer and tell you how to make contact with him/her.

    • We must train our staff to follow the privacy rules and we discipline them when they do not.

    • We must monitor our compliance and take steps to improve any weak areas.

    • We must notify you if we accidentally release your Protected Health Information to someone who should not have the information.

    • We reserve the right to change the terms of this notice and to make any new notice provisions effective for all protected health information. The revised notice will be posted on the website.


If you believe that we have not protected your health care information properly, you have a right to file a complaint. We will take your complaint very seriously and investigate the complaint completely.

To make a complaint, please write a letter and mail or give to our Privacy Officer Richard P. Walsh, MD 960 West Wooster Street, Suite 105, Bowling Green, Ohio 43402, or call him at (419) 353-6262.

This notice is effective September 9, 2013, and will remain in effect until a new notice is issued.

Dr. Richard P. Walsh

960 W Wooster St, Ste105
Bowling Green, OH 43402

PHONE: (419) 353-6262



8:30 am - 7:00 pm

Tuesday & Thursday
8:30 am - 5:00 pm

8:30 am - noon

8:00 am - 2:00 pm