Title: Menorah Park Center for Senior Living v. Rolston

State: ohio

Issuer: Ohio Supreme Court

Document:

[Until this opinion appears in the Ohio Official Reports advance sheets, it may be cited as 
Menorah Park Ctr. for Senior Living v. Rolston, Slip Opinion No. 2020-Ohio-6658.] 
 
 
 
NOTICE 
This slip opinion is subject to formal revision before it is published in an 
advance sheet of the Ohio Official Reports.  Readers are requested to 
promptly notify the Reporter of Decisions, Supreme Court of Ohio, 65 
South Front Street, Columbus, Ohio 43215, of any typographical or other 
formal errors in the opinion, in order that corrections may be made before 
the opinion is published. 
 
 
SLIP OPINION NO. 2020-OHIO-6658 
MENORAH PARK CENTER FOR SENIOR LIVING, APPELLANT, v. ROLSTON, 
APPELLEE. 
[Until this opinion appears in the Ohio Official Reports advance sheets, it 
may be cited as Menorah Park Ctr. for Senior Living v. Rolston, Slip Opinion 
No. 2020-Ohio-6658.] 
Torts—Medical 
providers—Disclosure 
of 
patients’ 
confidential 
health 
information—Health Insurance Portability and Accountability Act of 1996 
(“HIPAA”) and HIPAA Privacy Rule—HIPAA does not preclude a claim 
for breach of physician-patient confidentiality when the limited disclosure 
of medical information was part of a court filing for the purpose of 
obtaining past-due payment on an account for medical services—There is 
an exception to liability when a medical provider makes a reasonable effort 
to limit the disclosure of the patient’s medical information to the minimum 
amount necessary to file a successful complaint for the recovery of unpaid 
charges for medical services—Court of appeals’ judgment reversed and 
cause remanded to trial court. 
SUPREME COURT OF OHIO 
 
2
(No. 2019-0939—Submitted August 4, 2020—Decided December 15, 2020.) 
APPEAL from the Court of Appeals for Cuyahoga County, 
No. 107615, 2019-Ohio-2114. 
_________________ 
KENNEDY, J. 
{¶ 1} In this appeal from a judgment of the Eighth District Court of 
Appeals, we address the interplay between the Health Insurance Portability and 
Accountability Act of 1996 (“HIPAA”), Pub.L. No. 104-191, 110 Stat. 1936, the 
subsequent HIPAA Privacy Rule promulgated in 45 C.F.R. 160 and 164, and 
Ohio’s common-law cause of action for the unauthorized, unprivileged disclosure 
by a medical provider to a third party of nonpublic medical information recognized 
by this court in Biddle v. Warren Gen. Hosp., 86 Ohio St.3d 395, 715 N.E.2d 518 
(1999).  We hold that HIPAA does not preclude a claim under our decision in Biddle 
when the limited disclosure of medical information was part of a court filing for the 
purpose of obtaining a past-due payment on an account for medical services. 
{¶ 2} However, we also hold that there is an exception to liability under our 
decision in Biddle when a medical provider makes a reasonable effort to limit the 
disclosure of the patient’s medical information to the minimum amount necessary 
to file a successful complaint for the recovery of unpaid charges for medical 
services.  We conclude that a provider of medical services acts reasonably to limit 
the release of health information to the minimum amount necessary to file a 
successful complaint for payment on a past-due account for medical services when 
the medical provider attaches to the complaint, pursuant to Civ.R. 10(D), medical 
bills that disclose the medical provider’s name and address, the patient’s name and 
address, the dates on which services were provided, billing or procedure codes, a 
description of the general category of services provided, and the amounts charged, 
paid, and due. 
January Term, 2020 
 
3
{¶ 3} Because the medical provider in this case limited its disclosure of 
information to the minimum amount necessary for it to assert a cause of action to 
recover from the patient payment for unpaid medical bills, the patient has failed to 
state a claim under our decision in Biddle.  Therefore, we reverse the judgment of 
the court of appeals on that claim. 
I.  FACTUAL AND PROCEDURAL BACKGROUND 
{¶ 4} Appellant, Menorah Park Center for Senior Living (“Menorah Park”), 
filed a small-claims complaint against appellee, Irene Rolston, in the Shaker 
Heights Municipal Court on March 21, 2018.  Menorah Park alleged that Rolston 
had failed to pay a debt in the amount of $463.53 “for therapy services [that] were 
provided by Menorah Park” when Rolston “was at Menorah Park for 
rehabilitation.”  Attached to Menorah Park’s complaint were copies of two billing 
statements.  Civ.R. 10(D)(1) provides, “When any claim or defense is founded on 
an account or other written instrument, a copy of the account or written instrument 
must be attached to the pleading.  If the account or written instrument is not 
attached, the reason for the omission must be stated in the pleading.” 
{¶ 5} The billing statements included a description of the medical services 
that Menorah Park had provided to Rolston, the dates on which the services were 
provided, medical-procedure codes, charges and credits, balances on Rolston’s 
account, and the names and addresses of Menorah Park and Rolston.  On the billing 
statements, the descriptions of the services provided to Rolston included “PT 
EVALUATION MOD COMPLEX,” “PT-MANUAL THERAPY,” “PT-
PHYSICAL PERFORMANCE TE,” and “PT THERAPEUTIC PROC-
AQUATI[C].”  (Capitalization sic.) 
{¶ 6} Rolston successfully moved for the case to be transferred to the 
municipal court’s regular docket and on May 1, 2018, she filed an answer and class-
action counterclaim against Menorah Park for breach of confidence for the 
disclosure to a third party of “nonpublic medical information that it learned within 
SUPREME COURT OF OHIO 
 
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a physician-patient relationship.”  Menorah Park moved to dismiss the 
counterclaim under Civ.R. 12(B)(6), arguing that HIPAA allows the disclosure of 
protected health information for the purpose of a medical provider’s obtaining 
payment for medical services.  Menorah Park argued that its actions had met the 
requirements under HIPAA and that even if it had failed to meet those 
requirements, HIPAA does not allow for a private cause of action for HIPAA 
violations. 
{¶ 7} In responding to the motion to dismiss, Rolston countered that 
Menorah Park’s disclosure of her medical information was not authorized under 
HIPAA, because HIPAA provides that when a medical provider seeks payment the 
provider is required to make reasonable efforts to limit the disclosure of information 
to the minimum amount necessary to obtain payment.  Rolston also argued that 
HIPAA does not preclude a common-law claim under our decision in Biddle, in 
which this court recognized that “an independent tort exists for the unauthorized, 
unprivileged disclosure to a third party of nonpublic medical information that a 
physician or hospital has learned within a physician-patient relationship,” 86 Ohio 
St.3d 395, 715 N.E.2d 51, at paragraph one of the syllabus. 
{¶ 8} The trial court granted Menorah Park’s motion to dismiss Rolston’s 
counterclaim, determining that “th[e] claim does not fall under the tort law claim 
established in Biddle * * * and the Defendant cannot sue on HIPAA grounds.”  In 
a nunc pro tunc entry, the trial court determined that its judgment dismissing 
Rolston’s counterclaim was a final, appealable order and that there was no just 
cause for delay. 
{¶ 9} The Eighth District reversed the trial court’s judgment, holding that 
Rolston had not failed to state a claim upon which relief can be granted.  Construing 
the allegations in Rolston’s complaint in her favor, the court concluded that Rolston 
had a potential claim under Biddle and that HIPAA does not preempt such a state 
common-law claim.  2019-Ohio-2114, 137 N.E.3d 682, ¶ 23. 
January Term, 2020 
 
5
{¶ 10} This court accepted Menorah Park’s jurisdictional appeal on two 
propositions of law: 
 
1. The Health Insurance Portability & Accountability Act 
(HIPAA) preempts a common law claim brought under Biddle v. 
Warren Gen. Hospital, 86 Ohio St.3d 395, 715 N.E.2d 518 (1999), 
for disclosure of protected health information where the limited 
disclosure was for the purpose of obtaining payment on a past due 
account, which is an “authorized disclosure” under HIPAA 
regulations. 
2. A claimant’s reliance on a HIPAA regulation to determine 
whether the release of protected health information was 
“unauthorized” for the purpose of pursuing a common law claim 
under Biddle would allow private enforcement of HIPAA 
regulations, which is contrary to overwhelming legal authority that 
HIPAA does not provide a private right of action for improper 
disclosures of medical information but rather provides civil and 
criminal penalties which must be enforced by the Department of 
Health and Human Services. 
 
(Emphasis sic.)  See 157 Ohio St.3d 1427, 2019-Ohio-4003, 131 N.E.3d 977. 
{¶ 11} After oral argument, this court sua sponte ordered the parties to brief 
the following issue:  
 
Should this court overturn or modify the holding in Biddle v. 
Warren Gen. Hospital, 86 Ohio St.3d 395, 715 N.E.2d 518 (1999), 
in light of the enactment of Health Insurance Portability and 
Accountability Act of 1996 (“HIPAA”), Pub.L. No. 104-191, 110 
SUPREME COURT OF OHIO 
 
6
Stat. 1936, and the subsequent promulgation of the HIPAA Privacy 
Rule, 45 C.F.R. Parts 160 and 164? 
 
See 159 Ohio St.3d 1405, 2020-Ohio-3206, 146 N.E.3d 582. 
II.  LAW AND ANALYSIS 
A.  Standard of Review 
{¶ 12} This court applies a de novo standard of review to orders granting a 
Civ.R. 12(B)(6) motion to dismiss.  Lunsford v. Sterilite of Ohio, L.L.C., ___ Ohio 
St.3d ___, 2020-Ohio-4193, ___ N.E.3d ___, ¶ 22.  “In reviewing a motion to 
dismiss for failure to state a claim upon which relief can be granted, we accept as 
true all factual allegations in the complaint.”  Id., citing Mitchell v. Lawson Milk 
Co., 40 Ohio St.3d 190, 192, 532 N.E.2d 753 (1988).  “A complaint should not be 
dismissed unless it appears ‘beyond doubt from the complaint that the plaintiff can 
prove no set of facts entitling him to recovery.’ ”  Id., quoting O’Brien v. Univ. 
Community Tenants Union, Inc., 42 Ohio St.2d 242, 327 N.E.2d 753 (1975), 
syllabus. 
B.  Biddle v. Warren Gen. Hosp. 
{¶ 13} In Biddle, this court recognized an independent tort for the 
unauthorized, unprivileged disclosure to a third party of nonpublic medical 
information that a physician or hospital obtained from a physician-patient 
relationship.  86 Ohio St.3d 395, 715 N.E.2d 51, at paragraph one of the syllabus.  
In Biddle, the hospital had given its patients’ medical information to a law firm so 
that the firm could determine whether the hospital’s patients who had unpaid 
medical bills could be eligible for Supplemental Security Income disability 
benefits, meaning that their unpaid medical bills could possibly be paid by the 
Social Security Administration.  Id. at 395-396.  The firm informed the hospital that 
in order to perform that service and screen the patients, it would be necessary for 
the hospital to provide four pieces of information: name, telephone number, age, 
January Term, 2020 
 
7
and medical condition.  Id. at 396.  The firm then contacted the patients to inform 
them of their potential rights in regard to disability coverage.  Id. 
{¶ 14} The plaintiffs in Biddle were people whose hospital-registration 
forms had been provided to the law firm by the hospital without prior authorization.  
Id.  They alleged several causes of action from that same factual root—mainly that 
the arrangement between the hospital and the law firm constituted a breach of 
physician-patient confidentiality—which included claims of invasion of privacy, 
intentional infliction of emotional distress, and negligence.  Id. at 397.  This court 
noted that it had long been the law in Ohio that a physician could be held liable for 
the unauthorized disclosure of medical information, but it also noted that courts in 
Ohio and elsewhere had failed to provide “a legal identity for an actionable breach 
of patient confidentiality.”  Id. at 400.  This court recognized that in an effort to 
establish a civil remedy for such an evident wrongdoing, courts had shoehorned a 
breach-of-confidence theory of recovery into many traditional legal theories—e.g., 
invasion of privacy, defamation, implied breach of contract, intentional and 
negligent infliction of emotional distress, implied private statutory causes of action, 
breach of trust, detrimental reliance, negligence, and medical malpractice—all of 
which are ill-suited for the purpose of addressing a breach-of-confidence situation.  
Id.  But this court noted the movement by some courts toward recognizing that an 
action for breach of confidence should “stand in its own right,” and that 
“increasingly courts have begun to adopt it as an independent tort in their respective 
jurisdictions.”  Id.  This court therefore decided in Biddle to recognize an 
independent tort “for the unauthorized, unprivileged disclosure to a third party of 
nonpublic medical information that a physician or hospital has learned within a 
physician-patient relationship.”  Id. at 401. 
{¶ 15} Although we recognized that specific cause of action, this court was 
quick to add that there are exceptions to liability for disclosure.  As we pointed out 
SUPREME COURT OF OHIO 
 
8
in Roe v. Planned Parenthood Southwest Ohio Region, 122 Ohio St.3d 399, 2009-
Ohio-2973, 912 N.E.2d 61, ¶ 47-48, 
 
Biddle * * * addressed liability for unauthorized disclosure 
and stressed the utmost importance of the patient’s right to 
confidentiality of medical communications. * * * However, 
paragraph two of the syllabus in Biddle addressed the defenses to the 
tort 
of 
unauthorized 
disclosure 
of 
confidential 
medical 
information—i.e., the circumstances under which a physician or 
hospital may release confidential medical records in the absence of 
a waiver without incurring tort liability. 
 
(Emphasis sic.) 
{¶ 16} We have therefore explained that the duty to maintain confidentiality 
recognized in Biddle is not absolute and that in some instances the privilege exists 
for a medical provider to disclose medical information.  In Biddle, this court 
identified particular instances in which the disclosure of confidential medical 
information is privileged, because statutes require the reporting of diseases that are 
infectious, contagious, or dangerous to public health, R.C. 3701.24, 3701.52, and 
3707.06, medical conditions that are indicative of child abuse or neglect, R.C. 
2151.421, and injuries that are indicative of criminal conduct, R.C. 2921.22.  
Biddle, 86 Ohio St.3d at 401-402, 715 N.E.2d 51. 
{¶ 17} Still, this court in Biddle did not limit the privilege to disclose 
medical information to instances when a physician or hospital has a statutory duty 
to disclose; “the privilege to disclose is not necessarily coextensive with a duty to 
disclose.”  Id. at 402.  A breach of confidentiality is actionable “ ‘only if it is 
wrongful, that is to say, without justification or excuse.’ ” Id., quoting MacDonald 
v. Clinger, 446 N.Y.S.2d 801, 805, 84 A.D.2d 482 (1982).  The duty of 
January Term, 2020 
 
9
confidentiality must yield in appropriate circumstances when there is a 
countervailing public interest.  Id.  “[S]pecial situations may exist where the interest 
of the public, the patient, the physician, or a third person are of sufficient 
importance to justify the creation of a conditional or qualified privilege to disclose 
in the absence of any statutory mandate or common-law duty.”  Id.  Therefore, we 
held:  
 
In the absence of prior authorization, a physician or hospital 
is privileged to disclose otherwise confidential medical information 
in those special situations where disclosure is made in accordance 
with a statutory mandate or common-law duty, or where disclosure 
is necessary to protect or further a countervailing interest which 
outweighs the patient’s interest in confidentiality. 
 
Id. at paragraph two of the syllabus. 
{¶ 18} Whether the ability of medical providers to disclose confidential 
information when seeking payment through legal action is a “countervailing 
interest which outweighs the patient’s interest in confidentiality,” id., and is 
therefore an exception to a Biddle claim, is the focus of this case.  But first we must 
address whether HIPAA  regulations, which were enacted after our decision in 
Biddle, preempt all common-law claims under Biddle. 
C.  HIPAA 
{¶ 19} HIPAA has several purposes, including making improvements to the 
portability and continuity of health-insurance coverage, combatting healthcare 
fraud and healthcare abuse, and simplifying the administration of health insurance.  
Tovino, A Timely Right to Privacy, 104 Iowa L.Rev. 1361, 1367 (2019).  HIPAA 
established patient-privacy protection—it stated that if Congress failed to enact 
comprehensive privacy legislation within three years of HIPAA’s enactment in 
SUPREME COURT OF OHIO 
 
10 
1996, the United States Department of Health and Human Services (“HHS”) would 
be required to issue regulations protecting the privacy of individually identifiable 
health information.  Id. at 1368.  Less than two months after this court’s decision 
in Biddle, HHS issued a proposed privacy rule on November 3, 1999, regulating 
the uses and disclosures of protected health information.  See id.  After 
modifications, a final rule went into effect in December of 2000.  Id.  Further 
changes were made to the rule in 2002, id., and again in 2009 with the enactment 
of the Health Information Technology for Economic and Clinical Health Act, 42 
U.S.C. 17932, 17933, 17934, 17935, and 17939, and HHS implemented more rules 
in 2013, id. at 1369.  “[T]he HIPAA Privacy Rule strives to balance the interest of 
individuals in maintaining the confidentiality of their health information with the 
interests of society in obtaining, using, and disclosing health information to carry 
out a variety of public and private activities.”  Id. 
{¶ 20} The HIPAA Privacy Rule provides to patients certain rights 
regarding their protected health information.  They have a right to receive a notice 
of privacy practices, a right to request additional privacy protections, a right to 
access their protected health information, a right to request an amendment of that 
protected health information, and a right to receive accounting disclosures 
regarding their protected health information.  Id. at 1371.  The Privacy Rule 
includes use and disclosure requirements that apply to “covered entities,” which 
include health plans, healthcare clearinghouses, and “health care provider[s] who 
transmit[] any health information in electronic form in connection with [standard] 
transaction[s].”  45 C.F.R. 160.103.  The requirements also apply to “business 
associates” of the covered entities.  42 U.S.C. 17934.  Business associates are 
associates outside the workforce of the covered entity that provide legal, actuarial, 
consulting, and other services to the covered entity.  45 C.F.R. 160.103. 
{¶ 21} The authorization required to disclose or use a patient’s protected 
health information depends on the nature of the use.  For some purposes, such as 
January Term, 2020 
 
11 
including a patient in a directory of individuals in a facility, the covered entity must 
inform the patient in advance and give the patient the opportunity to agree to or 
prohibit or restrict that disclosure.  C.F.R. 164.510.  In other instances, such as those 
involving the sale of medical information, a signed authorization is required.  
C.F.R. 164.508. 
{¶ 22} But in certain instances, the HIPAA Privacy Rule allows covered 
entities to use and disclose protected health information without first obtaining 
authorization from the patient.  Pursuant to C.F.R. 164.502(a)(1)(ii), a covered 
entity is permitted to use or disclose protected health information “[f]or treatment, 
payment, or health care operations * * *.”  (Emphasis added.)  But regarding the 
use of protected health information for such purposes, the HIPAA Privacy Rule 
limits the use or disclosure of the information to the minimum amount necessary to 
achieve the purpose of the use:  
 
Minimum necessary applies.  When using or disclosing 
protected health information or when requesting protected health 
information from another covered entity or business associate, a 
covered entity or business associate must make reasonable efforts to 
limit protected health information to the minimum necessary to 
accomplish the intended purpose of the use, disclosure, or request. 
 
45 C.F.R. 164.502(b)(1). 
{¶ 23} “The remedies available to patients who believe their privacy and 
security rights have been violated are limited.  Under current law, no private right 
of action exists for patients and insureds whose rights under the HIPAA Rules have 
been violated.”  Tovino at 1372; see also Boddie v. Van Steyn, 10th Dist. Franklin 
No. 13AP-623, 2014-Ohio-1069, ¶ 18 (collecting cases determining there is no 
private cause of action under Ohio law for HIPAA violations); Hill v. Smoot, 308 
SUPREME COURT OF OHIO 
 
12 
F.Supp.3d 14, 23 (D.D.C.2018) (“ ‘Every district court that has considered this 
issue is in agreement that the statute does not support a private right of action’ ”), 
quoting Acara v. Banks, 470 F.3d 569, 571 (5th Cir.2006). 
{¶ 24} There are other avenues for redress that patients who believe that 
their privacy and security rights have been violated may take.  They can file a 
complaint with the covered entity itself under 45 C.F.R. 164.530(d)(1), which 
allows the covered entity to impose sanctions on members of its workforce, 45 
C.F.R. 164.530(e)(1).  An aggrieved person can file a complaint with the secretary 
of HHS.  45 C.F.R. 160.306(a).  HHS can impose a civil money penalty—ranging 
from $100 to $50,000 per violation, with maximum penalties of $25,000 or 
$1,500,000 per calendar year, 42 U.S.C. 1320d-5(a)(3)—or it can refer the case to 
the United States Department of Justice for criminal prosecution, Tovino at 1373; 
42 U.S.C. 1320d-6(b).  42 U.S.C. 1320d-5(d) authorizes a state’s attorney general 
to bring a civil action on behalf of residents of the state for violations of the HIPAA 
Privacy Rule.  The state’s attorney general can attempt to enjoin further violations 
by the covered entity or sue for damages for up to $100 per violation, not to exceed 
$25,000 in a calendar year.  Id. 
{¶ 25} Although HIPAA provides for the sanctioning of covered entities 
that violate the Privacy Rule,  HIPAA creates no private cause of action for a 
violation of its rules or regulations.  We must next determine whether HIPAA 
precludes a patient from bringing a state-law cause of action for a breach of 
confidentiality. 
D.  The relationship between HIPAA and state law 
{¶ 26} In English v. Gen. Elec. Co., 496 U.S. 72, 78-79, 110 S.Ct. 2270 
(1990), the United States Supreme Court described three ways by which federal 
law can preempt state law under the Supremacy Clause.  Those include when (1) 
Congress expressly preempts state law (express preemption), (2) Congress has 
occupied the entire field (field preemption), and (3) there is an actual conflict 
January Term, 2020 
 
13 
between federal and state law (conflict preemption).  In the HIPAA statutory and 
regulatory scheme, Congress has demonstrated no intention to occupy the entire 
field of medical privacy; instead, the HIPAA-related statutes and rules provide that 
federal law preempts state law when there is an actual conflict between the laws, 
and even that preemption is subject to significant exceptions. 
{¶ 27} 42 U.S.C. 1320d-7(a)(1) states that HIPAA “shall supersede any 
contrary provision of State law.”  The HIPAA regulations echo that statement: “A 
standard, requirement, or implementation specification adopted under this 
subchapter that is contrary to a provision of State law preempts the provision of 
State law.”  45 C.F.R. 160.203.  State law is contrary to HIPAA when (1) it is 
“impossible to comply with both the State and Federal requirements” or (2) “[s]tate 
law stands as an obstacle to the accomplishment and execution” of the act.  45 
C.F.R. 160.202.  45 C.F.R. 160.202 defines a state law to “mean[] a constitution, 
statute, regulation, rule, common law, or other State action having the force and 
effect of law.”  (Emphasis added.)  HIPAA does not prevail over a state law in 
every situation in which there is a conflict between HIPAA and the state law.  One 
exception to that general rule is when “[t]he provision of State law relates to the 
privacy of individually identifiable health information and is more stringent than a 
standard, requirement, or implementation specification adopted under [HIPAA].”  
45 C.F.R. 160.203(b).  The regulations define what is meant by “more stringent”: 
 
More stringent means, in the context of a comparison of a 
provision of State law and a standard, requirement, or 
implementation specification adopted under subpart E of part 164 of 
this subchapter, a State law that meets one or more of the following 
criteria: 
(1) With respect to a use or disclosure, the law prohibits or 
restricts a use or disclosure in circumstances under which such use 
SUPREME COURT OF OHIO 
 
14 
or disclosure otherwise would be permitted under this subchapter, 
except if the disclosure is: 
(i) Required by the Secretary in connection with determining 
whether a covered entity or business associate is in compliance with 
this subchapter; or 
(ii) To the individual who is the subject of the individually 
identifiable health information. 
* * *  
 (6) With respect to any other matter, provides greater 
privacy protection for the individual who is the subject of the 
individually identifiable health information. 
 
45 C.F.R. 160.202. 
{¶ 28} Therefore, even if HIPAA—a federal statute—created a safe harbor 
for a medical provider that releases certain protected patient information, that does 
not necessarily mean that such information can properly be released under state 
law; the patient may be protected to a greater degree by state law.  If the state law 
is more stringent than the HIPAA regulation, the state law applies.  See, e.g., Grove 
v. Northeast Ohio Nephrology Assoc., Inc., 164 Ohio App.3d 829, 2005-Ohio-6914, 
844 N.E.2d 400, ¶ 22-23 (9th Dist.) (protection for patient’s health information 
from discovery in a civil action is more stringent under Ohio law, R.C. 
2317.02(B)(1), than under HIPAA).  A HIPAA regulation preempts state law if 
there is a conflict between the HIPAA regulation and the state law and the state law 
is not more stringent than the HIPAA regulation.  Further, if a state law is not more 
stringent in that regard, it is not preempted unless it is contrary to HIPAA—that is, 
unless the state law makes it “impossible to comply with both the State and Federal 
requirements” or stands as “an obstacle to the accomplishment and execution” of 
HIPAA.  45 C.F.R. 160.202. 
January Term, 2020 
 
15 
E.  HIPAA does not preempt a state-law claim under our decision in Biddle 
{¶ 29} In Biddle, we recognized an independent tort for the “unauthorized, 
unprivileged disclosure to a third party of nonpublic medical information that a 
physician or hospital has learned within the physician-patient-relationship.”  86 
Ohio St.3d 395, 715 N.E.2d 518, at paragraph one of the syllabus.  Is Biddle 
contrary to HIPAA and therefore preempted by HIPAA?  Menorah Park argues that 
if its disclosure of Rolston’s nonpublic medical information to obtain payment of 
her debt is authorized by HIPAA and its regulations, then HIPAA preempts any 
common-law claim under our decision in Biddle.  But that argument ignores 
HIPAA and its subsequent rules, which state that more stringent state laws 
regarding the disclosure of medical information prevail over HIPAA and its 
regulations. 
{¶ 30} If our decision in Biddle were to mean that a covered entity is 
somehow permitted to release a patient’s protected health information that it could 
not release under HIPAA, then HIPAA would preempt Biddle.  But neither party 
makes that claim in this case.  And our determination in Biddle that Ohio recognizes 
an independent cause of action for such disclosure is not contrary to HIPAA under 
HIPAA’s own definition of the word “contrary”: the existence of a state-law private 
cause of action does not make it impossible for a covered entity to comply with 
both state and federal privacy requirements and does not stand in the way of the 
accomplishment of the aims of HIPAA.  Instead, “a Biddle claim enhances the 
protection of confidentiality of medical information.”  Sheldon v. Kettering Health 
Network, 2015-Ohio-3268, 40 N.E.3d 661, ¶ 25 (2d Dist.).  In a situation in which 
state law provides a patient the potential personal recovery of damages, it is not 
impossible for the covered entity to comply with both HIPAA and the state law 
“ ‘because both laws, in complementary rather than contradictory fashion, 
discourage a person from wrongfully disclosing information from another person’s 
health record.’ ”  R.K. v. St. Mary’s Med. Ctr., Inc., 229 W.Va. 712, 719, 735 S.E.2d 
SUPREME COURT OF OHIO 
 
16 
715 (2012), quoting Yath v. Fairview Clinics, N.P., 767 N.W.2d 34, 49 
(Minn.Ct.App.2009).  See  also Byrne v. Avery Ctr. for Obstetrics & Gynecology, 
P.C., 314 Conn. 433, 459, 102 A.3d 32 (2014) (“The availability of such private 
rights of action in state courts, to the extent that they exist as a matter of state law, 
do not preclude, conflict with, or complicate health care providers’ compliance with 
HIPAA”).  Biddle and HIPAA share the same goal of protecting the privacy of 
personal medical information.  Their remedies are different but they are not at odds 
with each other. 
F.  Exception under Biddle for complaints for bill collection 
{¶ 31} Having determined that HIPAA does not preempt claims brought 
under Biddle, we next consider whether one of the nondisclosure exceptions 
recognized in Biddle applies to Menorah Park’s disclosure in this case.  This court 
has not addressed the issue of a medical provider’s use of protected health 
information in the context of instituting a legal action for the payment of medical 
bills.  In Biddle, this court established that there are exceptions to liability for the 
unauthorized release of medical information.  We stated that “special situations 
may exist where the interest of the public, the patient, the physician, or a third 
person are of sufficient importance to justify the creation of a conditional or 
qualified privilege to disclose in the absence of any statutory mandate or common-
law duty.”  Biddle at 402.  We held in Biddle that a patient has no cause of action 
for a breach of confidentiality “where disclosure is made in accordance with a 
statutory mandate or common-law duty, or where disclosure is necessary to protect 
or further a countervailing interest which outweighs the patient’s interest in 
confidentiality.”  Id. at paragraph two of the syllabus.  Certainly, there is no 
statutory mandate or common-law duty that requires a medical provider to file a 
complaint in small-claims court to recover payment for unpaid medical bills.  That 
is a voluntary act by the medical provider.  However, the interest in receiving 
payment for medical services is a countervailing interest to the patient’s interest in 
January Term, 2020 
 
17 
confidentiality.  Is that interest enough to outweigh the patient’s interest in 
confidentiality? 
{¶ 32} We can look to HIPAA for guidance in determining how those 
competing interests should be weighed.  HIPAA permits the use or disclosure of 
protected health information “for treatment, payment, or health care operations.”  
(Emphasis added.)  45 C.F.R. 164.502(a)(1)(ii).  Payment means “activities 
undertaken by” a healthcare provider “to obtain or provide reimbursement for the 
provision of health care.”  45 C.F.R. 164.501.  When using protected health 
information for such purposes, the HIPAA Privacy Rule limits the use or disclosure 
of the information to the minimum amount necessary to achieve the purpose of the 
use.  Therefore, HIPAA recognizes that there is a balancing of interests between a 
medical provider and a patient vis-à-vis the provider’s efforts to collect payment 
for medical services.  The medical provider may disclose only the information 
necessary to recover payment.  The HIPAA Privacy Rule is a reflection of the 
legitimate governmental and societal interests in allowing medical providers to 
pursue payment for the medical services they provide and acknowledges that the 
disclosure of some of a patient’s medical information is a necessary part of that 
endeavor. 
{¶ 33} R.C. 3798.04 echoes HIPAA’s privilege for covered entities to use 
patient information to pursue payment for medical bills.  That statute provides that 
a covered entity shall not “[u]se or disclose protected health information without 
an authorization * * * except when the use or disclosure is required or permitted 
without such authorization by Subchapter C of Subtitle A of Title 45 of the Code 
of Federal Regulation,” which contains 45 C.F.R. 164.501 and 164.502. 
{¶ 34} We determine that the acknowledgement in HIPAA and Ohio law 
that the privacy interest of the patient must at least partially give way to the interest 
of the medical provider in obtaining payment reflects the type of countervailing 
interest recognized in Biddle that gives the medical provider a qualified privilege 
SUPREME COURT OF OHIO 
 
18 
to disclose patient information.  As in the HIPAA regulations, that interest is 
narrowed such that the covered entity may disclose only the minimum amount of 
patient information necessary to meet the interest, i.e., to sufficiently plead the 
claim.  A patient has a claim under Biddle if the doctor or hospital uses more than 
the minimum medical information necessary to sufficiently state a claim for 
recovery. 
{¶ 35} Accordingly, we hold that doctors and hospitals have a qualified 
privilege to disclose patient information for the purpose of receiving payment for 
medical services.  Therefore, a patient has no cause of action under Biddle when a 
medical provider discloses patient information in the minimum amount necessary 
to state a claim against the patient. 
{¶ 36} As noted above, it is well-settled that a HIPAA violation does not 
create a private cause of action for the party whose information has been released.  
By referring to a HIPAA standard to inform our recognition of an exception under 
Biddle for the disclosure of patient information for the purpose of receiving 
payment for medical services, we have not created a private cause of action for a 
HIPAA violation.  We have, instead, referred to HIPAA and Ohio law in limiting a 
common-law cause of action that recognizes an exception when disclosure is 
necessary to protect or further a countervailing interest that outweighs the patient’s 
interest in confidentiality. 
G.  The complaint in this case falls under a Biddle exception 
{¶ 37} When a healthcare provider uses protected health information to 
pursue the recovery of payment in court, it may release only as much information 
as is necessary to pursue its claim; otherwise a patient has a cause of action pursuant 
to Biddle for the unauthorized, unprivileged disclosure to a third party of nonpublic 
medical information that a physician or hospital has obtained within a physician-
patient relationship.  Civ.R. 10(D)(1) states that when a plaintiff files a claim 
January Term, 2020 
 
19 
founded on an unpaid account, the plaintiff must attach a copy of the account.  Ohio 
courts have explained this requirement: 
 
It is elementary that in an action on an account, a plaintiff 
must set forth an actual copy of the recorded account.  * * * The 
records must show “the name of the party charged” and must include 
the following: 
(1) a beginning balance (zero, or a sum that can qualify as an 
account stated, or some other provable sum); 
(2) listed items, or an item, dated and identifiable by number 
or otherwise, representing charges, or debits, and credits; and 
(3) summarization by means of a running or developing 
balance, or an arrangement of beginning balance and items which 
permits the calculation of the amount claimed to be due. 
 
Arthur v. Parenteau, 102 Ohio App.3d 302, 304-305, 657 N.E.2d 284 (3d 
Dist.1995), quoting Brown v. Columbus Stamping & Mfg. Co., 9 Ohio App.2d 123, 
126,  223 N.E.2d 373 (10th Dist.1967). 
{¶ 38} Menorah Park attached to its complaint copies of its two most recent 
bills to Rolston.  The bills contained no diagnosis or prognosis, no personal 
information other than Rolston’s name and address, and no detailed medical 
records.  They included no notes from therapists or doctors remarking on how 
Rolston responded to treatment and no indication of why she needed treatment in 
the first place.  The bills referred to no body part or medical condition.  The 
treatment reflected in the bills is described in general terms; the most detailed 
description indicates that Rolston received some aquatic therapy.  The medical bills 
included the provider’s name and address, Rolston’s name and address, the dates 
on which services were provided, billing or procedure codes, a description of the 
SUPREME COURT OF OHIO 
 
20 
general category of services provided, and the amounts charged, paid, and due.  We 
conclude that Menorah Park made reasonable efforts to limit the release of health 
information to the minimum amount necessary to inform Rolston—and later, the 
court—of the nature of the debt owed, and did not disclose medical information 
unnecessary to collect payment in an action on the account. 
{¶ 39} Therefore, we conclude that since Rolston’s cause of action is based 
upon the medical information disclosed in Menorah Park’s complaint, she has 
failed to state a claim upon which relief can be granted on her counterclaim.  The 
court of appeals erred in reversing the trial court’s judgment granting Menorah 
Park’s motion to dismiss. 
H.  We need not overturn or modify Biddle in this case 
{¶ 40} After oral argument, we instructed the parties to submit briefs 
addressing an issue that had not been considered in the lower courts—whether we 
should overrule or modify our decision in Biddle in this case.  Given our holding in 
this case, Biddle remains good law and it continues to permit a cause of action for 
the unauthorized, unprivileged disclosure to a third party of nonpublic medical 
information.  Our opinion today helps to define what constitutes privileged 
disclosure under Biddle. 
{¶ 41} Biddle was not wrongly decided nor was it revolutionary.  As Justice 
Deborah L. Cook recognized in her separate opinion in Biddle, independent torts 
for the unauthorized disclosure of medical information and for the inducement 
thereof had been recognized more than 30 years earlier in Hammonds v. Aetna Cas. 
& Sur. Co., 243 F.Supp. 793 (N.D.Ohio 1965).  Biddle, 86 Ohio St.3d at 409, 715 
N.E.2d 518 (Cook, J., concurring in part and dissenting in part). 
{¶ 42} Our decision in Biddle preceded the promulgation of the  HIPAA 
Privacy Rule.  HIPAA does not supplant the personal right to recovery that we 
recognized in Biddle.  As discussed above, a Biddle claim is not preempted by 
HIPAA and is in fact complementary and shares goals in common with HIPAA. 
January Term, 2020 
 
21 
{¶ 43} Subsequent to our decision in Biddle and the establishment of the 
HIPAA Privacy Rule, this court reiterated and extended its holding in Biddle.  See 
Hageman v. Southwest Gen. Health Ctr., 119 Ohio St.3d 185, 2008-Ohio-3343, 893 
N.E.2d 153.  In Hageman, we held that “[a]n attorney may be liable to an opposing 
party for the unauthorized disclosure of that party’s medical information that was 
obtained through litigation.”  Id. at syllabus.  We applied our holding in Biddle in 
the context of a divorce case in which a lawyer had given copies of the opposing 
party’s medical records, including psychiatric records, to a prosecutor.  Id. at ¶ 6.  
In that case, there was no direct involvement with a medical provider.  The lead 
opinion in Hageman pointed out that “Biddle stressed the importance of upholding 
an individual’s right to medical confidentiality beyond just the facts of that case.”  
Id. at ¶ 13. 
{¶ 44} Finally, the General Assembly has enacted medical-information-
privacy legislation that largely follows HIPAA.  R.C. 3798.02 states: 
 
It is the intent of the general assembly in enacting this 
chapter to make the laws of this state governing the use and 
disclosure of protected health information by covered entities 
consistent with, but generally not more stringent than, the HIPAA 
privacy rule for the purpose of eliminating barriers to the adoption 
and use of electronic health records and health information 
exchanges.  Therefore, it is also the general assembly’s intent in 
enacting this chapter to supersede any judicial or administrative 
ruling issued in this state that is inconsistent with the provisions of 
this chapter. 
 
“[I]t is long-settled constitutional law that it is within the power of the legislature 
to alter, revise, modify, or abolish the common law as it may determine necessary 
SUPREME COURT OF OHIO 
 
22 
or advisable for the common good.”  Arbino v. Johnson & Johnson, 116 Ohio St.3d 
468, 2007-Ohio-6948, 880 N.E.2d 420, ¶ 131 (Cupp, J., concurring).  The General 
Assembly had the ability to abolish Biddle claims when it enacted Ohio’s version 
of HIPAA.  It did not.  And there is no reason for us to overturn our decision in 
Biddle today. 
III.  CONCLUSION 
{¶ 45} We continue to recognize a common-law cause of action by a 
medical patient for the unauthorized, unprivileged disclosure by a medical provider 
to a third party of the patient’s nonpublic medical information.  See Biddle, 86 Ohio 
St.3d 395, 715 N.E.2d 518.  We hold that a claim under our decision in Biddle is 
not preempted by HIPAA and its subsequent privacy rule.  However, there are 
exceptions to liability under Biddle when the disclosure of medical information is 
necessary to protect or further a countervailing interest in disclosure that outweighs 
the patient’s interest in confidentiality.  After balancing the interests reflected in 
HIPAA, we conclude that a medical provider may disclose a limited amount of a 
patient’s medical information to further its efforts to collect unpaid bills from the 
patient for medical services.  Under our decision in Biddle, an exception for such a 
disclosure exists when the medical provider makes a reasonable effort to limit the 
disclosure of a patient’s medical information to the minimum amount necessary to 
file a successful complaint for the recovery of past-due charges for medical 
services.  We conclude that a medical provider discloses the minimum amount of 
medical information necessary to file a successful claim for unpaid medical-service 
bills when the medical provider attaches to its complaint, pursuant to Civ.R. 10(D), 
medical bills that disclose the medical provider’s name and address, the patient’s 
name and address, the dates on which services were provided, billing or procedure 
codes, a description of the general category of services provided, and the amounts 
charged, paid, and due. 
January Term, 2020 
 
23 
{¶ 46} Because Menorah Park limited its disclosure of Rolston’s medical 
information in its complaint to the minimum amount necessary to assert a cause of 
action to recover payment from Rolston for her unpaid medical bills, Rolston has 
failed to state a claim for relief under Biddle.  Therefore, we reverse the judgment 
of the Eighth District Court of Appeals on that issue and remand the cause to the 
Shaker Heights Municipal Court for further proceedings consistent with this 
opinion. 
Judgment reversed  
and cause remanded. 
FRENCH, J., concurs. 
O’CONNOR, C.J., concurs in part and dissents in part, with an opinion joined 
by STEWART, J. 
FISCHER, J., concurs in judgment only in part and dissents in part, with an 
opinion joined by DEWINE, J. 
DONNELLY, J., concurs in part and dissents in part, with an opinion. 
_________________ 
O’CONNOR, C.J., concurring in part and dissenting in part. 
{¶ 47} I agree with the majority’s conclusions in Parts II(E) and (H) of the 
above opinion.  I also agree with the majority’s conclusion in Part II(F) of that 
opinion that a medical provider that discloses patient information in a bill-collection 
action is not liable under our decision in Biddle v. Warren Gen. Hosp., 86 Ohio 
St.3d 395, 715 N.E.2d 518 (1999), if its disclosure is limited to the minimum 
amount of information necessary to obtain payment.  I disagree, however, with the 
decision to address an additional issue, found in Part II(G) of that opinion.  That 
part of the opinion applies the new minimum-necessary standard announced here 
to appellee Irene Rolston’s class-action counterclaim and concludes that appellant, 
Menorah Park Center for Senior Living, made reasonable efforts to limit the release 
SUPREME COURT OF OHIO 
 
24 
of Rolston’s heath information and that the information disclosed does not reveal 
more than the minimum amount of information necessary to obtain payment. 
{¶ 48} To start, I am at a loss for what “reasonable efforts” Menorah Park 
made to limit the disclosure of Rolston’s information.  Menorah Park simply 
attached an unredacted copy of Rolston’s account statement to its complaint.  
Although Civ.R. 10(D)(1) states that a copy of an account that is the basis of an 
action must be attached to the pleading, the rule does not require the document to 
be in its original, unredacted form.  Indeed, the rule even goes so far as to permit a 
complaint to be filed with no account statement or written instrument attached as 
long as there is an explanation for the omission in the pleading.  Menorah Park 
undertook none of these efforts.  Is that reasonable? 
{¶ 49} Next, the opinion acknowledges that the trial court dismissed 
Rolston’s counterclaim at the Civ.R. 12(B)(6) stage and that the minimum-
necessary standard is a defense to a Biddle claim, not an element thereof.  See Roe 
v. Planned Parenthood Southwest Ohio Region, 122 Ohio St.3d 399, 2009-Ohio-
2973, 912 N.E.2d 61, ¶ 47-48, citing Biddle at paragraph two of the syllabus.  Given 
this, the trial court should be given the first opportunity to consider Menorah Park’s 
defense under the new minimum-necessary standard—including what information 
suffices as the minimum amount necessary and whether protections against 
disclosure such as redactions should be employed—at the appropriate point in the 
case, if raised. 
{¶ 50} In light of the majority’s conclusions in Parts II(E), (F), and (H) of 
the above opinion, this court should refrain from addressing the matters discussed 
in Part II(G) and instead remand the case for further proceedings consistent with 
the court’s opinion.  Because the conclusion in Part II(G) of the opinion leads it to 
reverse the judgment of the Eighth District Court of Appeals and to reinstate the 
trial court’s judgment dismissing Rolston’s counterclaim, I dissent in part. 
January Term, 2020 
 
25 
STEWART, J., concurs in the foregoing opinion. 
_________________ 
FISCHER, J., concurring in judgment only in part and dissenting in part. 
{¶ 51} I agree that this court should reverse the judgment of the Eighth 
District Court of Appeals.  Respectfully, however, I would reach that outcome by 
simply overruling this court’s decision in Biddle v. Warren Gen. Hosp., 86 Ohio 
St.3d 395, 715 N.E.2d 518 (1999). 
{¶ 52} This court may overrule its precedent when (1) “changes in 
circumstances no longer justify continued adherence to the decision,” (2) “the 
decision defies practical workability,” and (3) “abandoning the precedent would 
not create an undue hardship for those who have relied upon it.”  Westfield Ins. Co. 
v. Galatis, 100 Ohio St.3d 216, 2003-Ohio-5849, 797 N.E.2d 1256, paragraph one 
of the syllabus.  Because I think that our decision in Biddle meets all of these 
conditions, I would overrule it. 
{¶ 53} First, the legal landscape today is drastically different than it was 
when Biddle was decided.  In 1999, when this court issued its decision in Biddle, 
there was no uniform regulatory system governing the disclosure of medical 
information.  As a result, that regulatory gap was often filled by the courts, which 
fashioned common-law causes of action for a medical provider’s breach of 
confidence.  See generally Alan B. Vickery, Breach of Confidence: An Emerging 
Tort, 82 Colum.L.Rev. 1426 (1982).  Following Biddle, however, the United States 
Department of Health and Human Services, under its rulemaking authority derived 
from the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 
Pub.L. No. 104-191, 110 Stat. 1936, promulgated the HIPAA Privacy Rule found 
in 45 C.F.R. 160 and 164 and established a system of comprehensive standards to 
protect an individual’s medical and health information.  Consequently, the problem 
that led to our decision in Biddle was largely solved. 
SUPREME COURT OF OHIO 
 
26 
{¶ 54} Next, at least comparatively, that legislative and regulatory solution 
is far more practical and workable than Biddle, which, with its vague generalities, 
e.g., “special situations” and “countervailing public interest[s],” 86 Ohio St.3d at 
402, 715 N.E.2d 518, is unclear about what disclosures are authorized and what 
disclosures may result in liability for hospital systems and medical providers.  
Despite the court’s thoroughness today, I suspect that Biddle will continue to defy 
practical workability because it will require a steady stream of cases like this one 
to properly define the contours of a claim and the scope of the duty (an event that 
those subject to liability under Biddle do not have the luxury of waiting around for). 
{¶ 55} Finally, since a breach of confidence can still result in liability under 
the federal scheme, see 42 U.S.C. 1320d-5, overruling Biddle would not result in 
an undue hardship for the patients that our decision in Biddle sought to protect.  
Simply put, the conduct that Biddle intended to discourage would still be deterred 
under the legislative and regulatory scheme developed after Biddle and in effect 
today.  Further, to the extent that it concludes that a private cause of action is 
necessary to protect patient confidentiality, the General Assembly is free to 
supplement the federal scheme by creating one.  The beauty of such an approach, 
of course, is that it would allow Ohio’s policymakers to provide a comprehensive 
set of rules from the outset and to decide whether such a cause of action should be 
broadly stated to provide recourse for a breach of the applicable federal- or state-
disclosure standards, see Cal.Civ.Code 56.35,  or narrowly stated to simply fill the 
gap left in HIPAA for noncovered entities, see Mont.Code Ann. 50-16-502 and 50-
16-505. 
{¶ 56} Accordingly, in this post-HIPAA Privacy Rule world, the 
protections provided in Biddle are no longer necessary or practical.  Since no undue 
hardship would result from doing so, I think that this court should overrule that 
decision.  Because this court does not do so on its way to reversing the Eighth 
January Term, 2020 
 
27 
District’s judgment in this case, I respectfully concur in the judgment of the court 
only in part and dissent in part. 
DEWINE, J., concurs in the foregoing opinion. 
_________________ 
DONNELLY, J., concurring in part and dissenting in part. 
{¶ 57} I agree with the vast bulk of the majority’s conclusions, including its 
holding that there is an exception to liability under our decision in Biddle v. Warren 
Gen. Hosp., 86 Ohio St.3d 395, 715 N.E.2d 518 (1999), when a medical provider 
makes a reasonable effort to limit the disclosure of the patient’s medical 
information to the minimum amount necessary to file a successful complaint for 
the recovery of unpaid charges for medical services. 
{¶ 58} But I disagree with the conclusion in Part II(G) regarding the 
application of that holding in this case.  Here, appellant, Menorah Park Center for 
Senior Living (“Menorah Park”), sought payment for services disclosed on the 
billing statements relating to physical-therapy services, including “PT 
EVALUATION MOD COMPLEX,” “PT-MANUAL THERAPY,” “PT-
PHYSICAL PERFORMANCE TE,” and “PT THERAPEUTIC PROC-
AQUATI[C].”  (Capitalization sic.)  Although I recognize that this information is 
not particularly illuminating with respect to the underlying health conditions or 
treatment provided, neither is it the minimum amount of information that would 
allow Menorah Park to pursue its claim for payment.  I believe an utterly generic 
phrase such as “services rendered” and the date the services were rendered would 
be the minimum amount necessary to file a successful complaint.  That general 
disclosure could be supplemented following an in camera review as the need arises.  
The use of such a generic phrase would result in no health information, even an 
admittedly rather nondescript term such as “therapy,” from being revealed to the 
public. 
SUPREME COURT OF OHIO 
 
28 
{¶ 59} In this case, Menorah Park revealed more than the minimum amount 
of medical information necessary to file a successful complaint.  Accordingly, I 
concur in part and dissent in part. 
_________________ 
 
Bonessi Switzer Polito & Hupp Co., L.P.A., Bret C. Perry, Brian F. Lange, 
and Jay Clinton Rice, for appellant. 
Ciano & Goldwasser, L.L.P., Andrew S. Goldwasser, and Sarah E. Katz; 
Powers Friedman Linn, P.L.L., and Robert G. Friedman; and Paul W. Flowers Co., 
L.P.A., Paul W. Flowers, and Louis E. Grube,  for appellee. 
Dinkler Law Office, L.L.C., Lynette Dinkler, and Carin Al-Hamdani, 
urging reversal for amicus curiae Ohio Association of Civil Trial Attorneys. 
Bricker & Eckler, L.L.P., Elizabeth A. Kastner, Victoria Flinn McCurdy, 
and Bryan M. Smeenk, urging reversal for amici curiae Ohio Hospital Association, 
Ohio State Medical Association, and Ohio Osteopathic Association. 
Tucker Ellis, L.L.P., Susan M. Audey, Raymond Krncevic, and Emily J. 
Johnson, urging reversal for amicus curiae Academy of Medicine of Cleveland & 
Northern Ohio. 
_________________