MESSAGE FROM THE CEO

Thank you for your interest in Avita Health System (Avita). I have been privileged to serve as Avita’s President and CEO since 2009. The creation of Avita Health System occurred when Bucyrus Community Hospital and Galion Community Hospital joined in 2011. The hard work and dedication given by the Board of Directors, Medical Staff, and employees has led to Avita’s ability to enhance services to the communities we serve. Avita has grown from approximately 450 employees in 2009 to over 1,800 employees who provide patient care in Crawford, Richland and Marion counties.

Avita is dedicated to providing an extraordinary patient experience and we are proud to have patient satisfaction scores ranking above most regional and national health systems, as measured by the independent patient satisfaction survey process (HCAPS) which is governed by the Federal CMS program. As a not-for-profit health system, we are blessed to be able to give back to the community by providing over twice the amount of uncompensated care to patients needing financial assistance when compared to other national and state health systems.

Avita is one of the few community health systems in Ohio that has not consolidated with a larger metropolitan health system. This means that Avita’s board members live locally, where health services are provided and utilized. The Avita Board realized how difficult it was to maintain local board governance in an era of mergers and acquisitions, which is why they decided to enhance their governance ability by using a comprehensive policy governance system. The policy governance system guides the board on how to effectively govern as a group in fulfilling their leadership role.

Avita truly has a corporate culture of collaboration, where the Board, Medical Staff and Employees work together to maximize Avita’s mission of improving the health and well-being of those we serve. Please explore the web site to find out more about the services Avita provides.
If you have any further questions, please feel free to contact us.

Sincerely,
Jerome Morasko
President and CEO

NOTICE OF PRIVACY PRACTICES

IMPORTANT:This notice describes how medical information about you may be used and disclosed and how you
can get access to this information. Please read it carefully.

Avita Health System and all employees at all it’s locations are required by law to maintain the privacy
of patients’ Protected Health Information (PHI) and to provide individuals with the following Notice of
the legal duties and privacy practices with respect to PHI. We are required to abide by the terms of
this Notice. We reserve the right to change the terms of this Notice and these new terms will affect
all PHI that we maintain at that time.

IN CERTAIN CIRCUMSTANCES WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT
YOUR WRITTEN CONSENT:

FOR TREATMENT:

We will use health information about you to provide you with medical treatment or services. We will
disclose PHI about you to doctors, nurses, technicians, students in health care training programs, or
other personnel who are involved in taking care of you. For example, a doctor treating you for a broken
leg may need to know if you have diabetes because diabetes might slow the healing process. In addition,
the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate
meals. Different departments of Avita may share health information about you in order to coordinate the
services you need, such as prescriptions, lab work and x-rays. We may disclose health information about
you to people outside Avita who provide your medical care like nursing homes or other doctors.

FOR PAYMENT:

We will use and disclose information to other health care providers to assist in the payment of your
bills. We will use it to send bills and collect payment from you, your insurance company, or other
payers, such as Medicare, for the care, treatment, and other related services you receive. We may tell
your health insurer about a treatment your doctor has recommended to obtain prior approval to determine
whether your plan will cover the cost of the treatment.

FOR HEALTH CARE OPERATIONS:

We may use and disclose PHI about you for the purpose of our business operations. These business uses
and disclosures are necessary to make sure that our patients receive quality care and cost effective
services. For example, we may use PHI to review the quality of our treatment and services, and to
evaluate the performance of our staff, contracted employees and students in caring for you.

BUSINESS ASSOCIATES:

We may use or disclose your PHI to an outside company that assists us in operating our health system.
They perform various services for us. This includes, but is not limited to, auditing, accreditation,
legal services, and consulting services. These outside companies are called “business associates” and
they contract with us to keep any PHI received from us confidential in the same way we do. These
companies may create or receive PHI on our behalf.

FAMILY MEMBERS AND FRIENDS:

If you agree, do not object, or we reasonably infer that there is no objection, we may disclose PHI
about you to a family member, relative, or another person identified by you who is involved in your
health care or payment for your health care. If you are not present or are incapacitated or it is an
emergency or disaster relief situation, we will use our professional judgment to determine whether
disclosing limited PHI is in your best interest under the circumstances. We may disclose PHI to a
family member, relative, or another person who was involved in the health care or payment for health
care of a deceased individual if not inconsistent with the prior expressed preferences of the
individual that are known to Avita. But you also have the right to request a restriction on our
disclosure of your PHI to someone who is involved in your care.

APPOINTMENTS:

We may use and disclose PHI to contact you for appointment reminders and to communicate necessary
information about your appointment.

CONTACTING YOU:

We may contact you about treatment alternatives or other health benefits or services that might be of
interest to you.

HOSPITAL DIRECTORIES:

When you are an inpatient admitted to the hospital, Avita hospitals may list certain information about
you, such as your name, your location in the hospital, a general description of your condition that
does not communicate specific medical information, and your religious affiliation, in a hospital
directory. The hospitals can disclose this information, except for your religious affiliation, to
people who ask for you by name. Your religious affiliation may be given to members of the clergy even
if they do not ask for you by name. You may request that no information contained in the directory be
disclosed. To restrict use of information listed in the directory, please inform the admitting staff or
your nurse. They will assist you in this request. In emergency circumstances, if you are unable to
communicate your preference, you will be listed in the directory.

FUNDRAISING ACTIVITIES:

We may use PHI, such as your name, address, phone number, the dates you received services, the
department from which you received service, your treating physician, outcome information, and health
insurance status to contact you to raise money for Avita interests. We may share this information with
a foundation associated with Avita Health System to work on our behalf. If you do not want Avita or its
affiliates to contact you for our fundraising and you wish to opt out these contacts, of if you wish to
opt back in to these contacts, you must call or email the Avita Health Foundation at 419-468-0566,
TSchott@avitahs.org.

REQUIRED OR PERMITTED BY LAW:

We may use or disclose your PHI when required or permitted to do so by federal, state, or local law

PUBLIC HEALTH ACTIVITES:

We may use or disclose your PHI for public health activities that are permitted or required by law. For
example, we may disclose your PHI in certain circumstances to control or prevent a communicable
disease, injury or disability; to report births and deaths; and for public health oversight activities
or interventions. We may disclose your PHI to the Food and Drug Administration (FDA) to report adverse
events or product defects, to track products, to enable product recalls, or to conduct post-market
surveillance as required by law or to a state or federal government agency to facilitate their
functions. We also may disclose protected health information, if directed by a public health authority,
to a foreign government agency that is collaborating with the public health authority.

HEALTH OVERSITE ACTIVITES:

We may disclose your PHI to a health oversight agency for activities authorized by law. For example,
these oversight activities may include audits; investigations; inspections; licensure or disciplinary
actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this
information include government agencies that oversee the health care system, government benefit
programs, other government regulatory programs, and government agencies that ensure compliance with
civil rights laws.

LAWSUITS AND OTHER LEGAL PROCEEDINGS:

We may disclose your PHI in the course of any judicial or administrative proceeding or in response to
an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized).
If certain conditions are met, we may also disclose your protected health information in response to a
subpoena, a discovery request, or other lawful process.

ABUSE OR NEGLECT:

We may disclose your PHI to a government authority that is authorized by law to receive reports of
abuse, neglect, or domestic violence. Additionally, as required by law, if we believe you have been a
victim of abuse, neglect, or domestic violence, we may disclose your protected health information to a
governmental entity authorized to receive such information.

LAW ENFORCEMENT:

Under certain conditions, we also may disclose your PHI to law enforcement officials for law
enforcement purposes. These law enforcement purposes include, by way of example, (1) responding to a
court order or similar process; (2) as necessary to locate or identify a suspect, fugitive, material
witness, or missing person; (3) reporting suspicious wounds, burns or other physical injuries; or (4)
as relating to the victim of a crime.

ABUSE OR NEGLECT:

We may disclose your PHI to a government authority that is authorized by law to receive reports of
abuse, neglect, or domestic violence. Additionally, as required by law, if we believe you have been a
victim of abuse, neglect, or domestic violence, we may disclose your protected health information to a
governmental entity authorized to receive such information.

TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY:

Consistent with applicable laws, we may disclose your PHI if disclosure is necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the public. We also may
disclose protected health information if it is necessary for law enforcement authorities to identify or
apprehend an individual.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS:

We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or to determine the cause of death. We may also release your PHI to a
funeral director, as necessary, to carry out his/her duties.

ORGAN, EYE, OR TISSUE DONATION:

We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.

RESEARCH:

Avita may use and share your health information for certain kinds of research. For example, a research
project may involve comparing the health and recovery of all patients who received one medication to
those who received another, for the same condition. All research projects, however, are subject to a
special approval process. In some instances, the law allows us to do some research using your PHI
without your approval.

WORKERS COMPENSATION:

We will disclose your health information that is reasonably related to a worker’s compensation illness
or injury following written request by your employer, worker’s compensation insurer, or their
representative.

EMPLOYEE SPONSORED HEALTH AND WELLNESS SERVICES:

We maintain PHI about employer sponsored health and wellness services we provide our patients,
including services provided at their employment site. We will use the PHI to provide you medical
treatment or services and will disclose the information about you to others who provide you medical
care.

SHARED MEDICAL RECORD/HEALTH INFORMATION EXCHANGES:

We maintain PHI about our patients in shared electronic medical records that allow Avita employees to
share PHI. We participate in one or more Health Information Exchanges. Your healthcare providers can
use this electronic network to securely provide access to your health records for a better picture of
your health needs. We and other healthcare providers, may allow access to your health information
through the Health Information Exchange for treatment, payment or other healthcare operations. This is
a voluntary agreement. You may opt-out at any time by notifying the Compliance/Ethics & Privacy
Director at 419.468.0614 or via email to CKropka@avitahs.org.

OTHER USES AND DISCLOSURES OF PHI:

Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes
and disclosures that constitute the sale of PHI require your written authorization.

Other uses and disclosures of your PHI that are not described above will be made only with your written
authorization. If you provide Avita with an authorization, you may revoke the authorization in writing,
and this revocation will be effective for future uses and disclosures of PHI. However, the revocation
will not be effective for information that we have used or disclosed in reliance on the authorization

YOUR RIGHTS REGARDING YOUR PHI::

THE RIGHT TO ACCESS TO YOUR OWN HEALTH INFORMATION:

You have the right to inspect and copy most of your protected health information for as long as we
maintain it as required by law. All requests for access must be made in writing as long as it does not
create an undue burden on you, or an unreasonable delay in you receiving the information. We may charge
you a nominal fee for each page copied and postage if applicable. You also have the right to ask for a
summary of this information. If you request a summary, we may charge you a nominal fee. Please contact
the Avita Health Information/Medical Records Department with any questions or requests

RIGHT TO REQUEST RESTRICTIONS:

You have the right to request certain restrictions of our use or disclosure of your PHI. We are not
required to agree to your request in most cases. But if Avita Health System agrees to the restriction,
we will comply with your request unless the information is needed to provide you emergency treatment.
Avita will agree to restrict disclosure of PHI about an individual to a health plan if the purpose of
the disclosure is to carry out payment or health care operations and the PHI pertains solely to a
service for which the individual, or a person other than the health plan, has paid Avita for in full.
For example, if a patient pays for a service completely out of pocket and asks Avita not to tell
his/her insurance company about it, we will abide by this request. A request for restriction should be
made in writing. To request a restriction you must contact Health Information/Medical Records
Department. We reserve the right to terminate any previously agreed-to restrictions (other than a
restriction we are required to agree to by law). We will inform you of the termination of the agreed-to
restriction and such termination will only be effective with respect to PHI created after we inform you
of the termination.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS:

If you believe that a disclosure of all or part of your PHI may endanger you, you may request in
writing that we communicate with you in an alternative manner or at an alternative location. For
example, you may ask that all communications be sent to your work address. Your request must specify
the alternative means or location for communication with you. It also must state that the disclosure of
all or part of the PHI in a manner inconsistent with your instructions would put you in danger. We will
accommodate a request for confidential communications that is reasonable and states that the disclosure
of all or part of your protected health information could endanger you.

RIGHT TO BE NOTIFIED OF A BREACH:

You have the right to be notified in the event that we (or one of our Business Associates) discovers a
breach of unsecured protected health information involving your medical information

RIGHT TO INSPECT AND COPY:

You have the right to inspect and receive a copy of PHI about you that may be used to make decisions
about your health. A request to inspect your records may be made to your nurse or doctor while you are
an inpatient or to the Health Information/ Medical Records Department while an outpatient. For copies
of your PHI, requests must go to the Health Information/Medical Records Department. For PHI in a
designated record set that is maintained in an electronic format, you can request an electronic copy of
such information. There may be a charge for these copies.

RIGHT TO AMEND:

If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the
information, for as long as Avita maintains the information. Requests for amending your PHI should be
made to the Health Information/Medical Records Department. The Avita personnel who maintain the
information will respond to your request within 60 days after you submit the written amendment request
form. If we deny your request, we will provide you a written explanation. You may respond with a
statement of disagreement to be appended to the information you wanted amended. If we accept your
request to amend the information, we will make reasonable efforts to inform others, including people
you name, of the amendment and to include the changes in any future disclosures of that information.

RIGHT TO AN ACCOUNTING:

With some exceptions, you have the right to receive an accounting of certain disclosures of your PHI. A
nominal fee will be charged for the record search.

COMPLAINTS:

You may submit any complaints with respect to violations of your privacy rights to the Avita Health
System Compliance/Ethics & Privacy Director. You may also file a complaint with the Secretary of
the U.S. Department of Health and Human Services if you feel that your rights have been violated. There
will be no retaliation from Avita for making a complaint.

CHANGES TO THIS NOTICE:

If we make a material change to this Notice, we will provide a revised Notice available at
www.avitahealth.org.

a complaint.

CONTACT INFORMATION:

Unless otherwise specified, to exercise any of the rights described in this Notice, for more
information, or to file a complaint, please contact the Privacy Officer at 419-468-0614.

VISITOR INFORMATION

We understand that no one looks forward to a stay in the hospital. That’s why, at Avita Health System,
we strive to make sure patient needs are met. Before your stay, we recommend that you take a minute or
two to look through our Patient Information Guides, available here on this page. During your stay, do
not hesitate to ask any member of our medical staff to help you make your stay with us as comfortable
as possible.

Visting hours are from 8:30am to 8:30pm

Patient Information Guide

PATIENT RIGHTS AND RESPONSIBILITIES

As a patient of Avita Health System, you have the right to:

  • Access to care and treatment, no matter your age, sex, race, color, religion, national
    origin, handicap, or ability to pay.
  • Respect, Consideration and Dignity with respectful care that recognizes your personal
    dignity and individuality.
  • Freedom from Abuse: Freedom from physical, verbal, mental, sexual and emotional abuse or
    harassment.
  • Freedom from Restraints and Seclusion of any form that is not medically necessary.
    Restraint and seclusion may not be used for punishment or staff convenience.
  • Privacy and Confidentiality in keeping with the law. You may expect any discussion
    involving your care to be discreet, and individuals not directly involved with your care will
    not be present without your permission. Your personal privacy will be protected.
  • Privacy of Your Medical Record and Confidentiality regarding your medical record. You
    have the right to access the information in your record within a reasonable time frame.
  • Safety while you are a patient and in our care.
  • Know the Identity of Caregivers and the role of staff providing care to you.
  • Prompt Notification of your doctor and your designated representative if you are
    admitted.
  • Communication and Access to Support, including visitors and written/phone communication,
    as long as it doesn’t interfere with your care or the care of other patients. If you need a
    translator or special equipment to communicate, we will arrange for those services at no cost
    to you.
  • Participate in Your Own Plan of Care: You, the patient, are the most important person in
    decisions about your healthcare. You have the right to be involved in care planning and
    treatment except when physically unable, medically inadvisable or contraindicated for medical
    reasons.
  • Refuse Treatment: You may refuse treatment, within the limits of the law.
  • Consultation: You may get a second opinion from another doctor or specialist (at your
    own request and cost).
  • Transfer and Continuity of Care and Information about a decision to transfer you to
    another facility for specialized services, including the alternatives to such a transfer. You
    also have the right to be informed by the staff of any discharge instructions or follow-up
    care.
  • Information and Consent about your illness and treatment options, communicated in a way
    you can understand. You have the right to make decisions regarding your care, and to be
    included in the consideration of ethical issues regarding your care. You will be allowed to
    decide whether or not to participate in any research, clinical trials or clinical training
    programs. When you cannot participate, information is provided to a person designated by you or
    to another legally authorized person.
  • Advance Directives: You may write an Advance Directive (Living Will and/or Durable Power
    of Attorney for Healthcare or doctor ordered “Do Not Resuscitate”). You can expect that your
    healthcare providers will provide care that is consistent with these directives.
  • Pain Management: You have the right to have your pain relieved as completely as
    possible.
  • Information About Your Healthcare Facility Charges and Rules: You may request and
    receive an itemized bill for services rendered in the healthcare facility. You have the right
    to know what the rules and regulations of the healthcare facility are so that you can comply
    with them.
  • Beneficiary Notice of Non-Coverage and the right to appeal a premature discharge with
    your payer.
  • Complain or File a Grievance: You may voice a complaint by giving it in writing, or
    asking to speak with someone in charge. The complaint will be forwarded to the appropriate
    member of leadership where it will be reviewed and addressed. Any employee can provide you with
    directions on how to file a complaint/grievance. This information is also available on the
    Avita website. For your convenience, it is also included here.

PATIENT RIGHTS AND RESPONSIBILITIES

The staff of Avita Health System will do everything we can to make sure that your care is appropriate
and prompt. If you are ever dissatisfied with your treatment, please approach a member of the staff and
they will attempt to resolve things as quickly as possible. You may also contact our Patient Relations
Coordinator by calling:

Our Patient Relations Coordinator will make sure your information is forwarded to leadership. If you
feel your concern was not adequately addressed, you may also file a complaint with someone outside the
healthcare facility.

The following organizations accept comments on Avita Health System:

DNV GL Healthcare: 866-523-6842

DNV GL Healthcare: mailto:hospitalcomplaint@dnv.com”

Ohio Department of Health: 800-669-3534

Medicare QIO KePro: 800-589-7337

The following organizations accept comments on Avita Ontario ASC:

Ohio Department of Health: 800-669-3534

Ohio Department of Health Complaint Unit
246 North High Street, Columbus, OH 43215
or e-mail at HCComplaints@odh.ohio.gov

Office of
Medicare Ombudsman

As a patient of Avita Health System, you have
responsibilities:

  • Provision of Information: Provide complete and accurate information to the best of your
    ability about your health history, present complaint, hospitalization, any medications,
    including over-the-counter products and dietary supplements, any allergies or sensitivities and
    any other matters pertaining to your health. You have the responsibility to report any changes
    in your condition to your healthcare provider.
  • Compliance with Instructions: Follow the treatment plan recommended by your
    practitioner, including the instructions of nurses and other health professionals as they carry
    out your plan of care. If you do not understand the information provided or your plan of care,
    you are responsible for asking questions. You must provide a responsible adult to take you home
    from the facility and remain with you for the amount of time your provider has told you. You
    are responsible for keeping appointments and, when unable to do so, for cancelling/rescheduling
    in a timely manner.
  • Refusal of Treatment: You are responsible for your actions if you refuse treatment or do
    not follow your practitioner’s instructions.
  • Healthcare Facility Regulations: Follow healthcare facility rules and regulations. You
    will be informed of rules that apply to you when you become a patient.
  • Respect and Consideration: Be considerate of the rights of other patients, staff, and
    healthcare facility property, including assisting in the control of noise and the number of
    visitors.
  • Advance Directives: Provide the healthcare facility with copies of Advance Directives if
    you have them so they can be followed in the event of a terminal illness or if you are unable
    to speak for yourself.
  • Healthcare Facility Charges: Be prompt to pay healthcare facility bills, to ask
    questions concerning the bill, and to provide the information necessary for insurance
    processing.

Patient education regarding rights and responsibilities:

Patients who are admitted to an Avita Health System hospital are offered a list of these rights and
responsibilities. They are also posted in registration areas.

MESSAGE FROM COMPLIANCE/ETHICS AND PRIVACY
DIRECTOR

Avita Health System’s Board of Directors pledges to its patients, staff, and the public that Avita is
an honest, ethical, and reputable healthcare system. Avita’s Compliance/Ethics and Privacy Program was
designed to show Avita’s commitment to operating in an ethical and honest manner by establishing
guidelines, processes, and policies designed to prevent and detect illegal conduct, provide education
and training, monitor operations, and business practices.

Avita strives to attain the highest ethical standards and to follow the laws, regulations and policies
that govern the healthcare industry. Avita’s staff is required to follow the Code of Conduct and to
conduct themselves with the utmost integrity.

The Compliance/Ethics and Privacy Committee is comprised of the Compliance/Ethics and Privacy Director,
the CEO, CFO, COO, and senior management, who together promote the reporting of illegal, inappropriate,
or unethical conduct.

If you have questions or concerns, please contact the Compliance/Ethics and Privacy Director, at 419-468-0571.

Cinda M. Kropka
Compliance/Ethics and Privacy Director

COMPLIANCE
PLAN AND CODE OF CONDUCT

HIPAA PRIVACY RULE
Most of us believe that our medical and other health information is private and should be protected,
and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over
your health information and sets rules and limits on who can look at and receive your health
information. The Privacy Rule applies to all forms of individuals’ protected health information,
whether electronic, written, or oral.

NOTICE OF PRIVACY PRACTICES
A Notice of Privacy Practices is a document that informs patients how Avita uses and discloses their
health information. The Notice also informs the patients when the provider can use or disclose their
health information with and without their permission, and informs the patient about rights to their
health information.

COMPLIANCE HOTLINE:419-468-0614
Avita’s Compliance Hotline may be used to report suspected illegal or unethical behavior. You can use
the hotline if you want to remain anonymous. Listen to the instructions, and then leave your message.
If you wish to be contacted, you may also leave your name and number. The Compliance/Ethics and Privacy
Director will review your message and thoroughly investigate your allegation.

There are other ways to report a suspected violation or concern:

  • Call the Compliance/Ethics and Privacy Director directly at 419-468-0571
  • Email the Compliance/Ethics and Privacy Director at CKropka@avitahs.org
  • Mail your report to:
    Compliance/Ethics and Privacy Director
    Avita Health System
    269 Portland Way S, Galion OH 44833

EXAMPLES OF ILLEGAL OR UNETHICAL BEHAVIOR

  • Submitting a false claim to Medicare or Medicaid
  • Kickbacks
  • Conflict of Interest
  • Unethical Business Practices
  • HIPAA Violations

OTHER CONTACT INFORMATION

  • At any time, or if you are not satisfied with Avita Health System’s response to your privacy
    concern, you may also contact the Office for Civil Rights at 800-368-1019
    or email OCRComplaint@hhs.gov
  • At any time, or if you are not satisfied with Avita Health System’s response to your concern of
    fraud, waste, or abuse, you may contact:Office of the Inspector General
    1-800-HHS-TIPS
    EmailCMS (Medicare):
    1-800-MEDICARE

MISSION, VISION AND VALUES

MISSION STATEMENT

The mission of Avita Health System is to improve the health and well-being of those we serve.


VISION STATEMENT

Avita Health System is a locally governed, patient centered, integrated health care system that is
committed to providing superior medical services to North Central Ohio. Avita Health System will be the
health care system and employer of choice, strategically use its resources to maximize the mission, and
strive for continual quality improvements.

VALUES STATEMENT

  • Accountable for our actions and attitudes.
  • Value patients by providing them with exceptional care and honoring their informed
    healthcare choices.
  • Integrity by having a commitment of doing what is right.
  • Teamwork by collaboratively working together.
  • Accept our leadership responsibility by leading strategically and focusing our resources
    to maximize Avita’s mission.