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As required by the Privacy
Regulations Created as a Result of the Health
Insurance Portability and Accountability Act of 1996
(HIPAA)
This notice describes how
health information about you (as a patient of this
practice) may be used and disclosed, an how you can
get access to your individually identifiable health
information.
Please review this notice
carefully
A. Our commitment to your privacy
Our practice is dedicated to maintaining the
privacy of your individually identifiable health
information, which has been designated as Protected
Health Information (PHI) by law. In conducting our
business, we will create records regarding you and
the treatment and services we provide to you. We are
required by law to maintain the confidentiality of
health information that identifies you. We are also
required by law to provide you with this notice of
our legal duties and the privacy practices that we
maintain in our practice concerning your PHI. By
federal and state law, we must follow the terms of
the notice of privacy practices that we have in
effect at the time.
We realize that these laws are complicated, but
we must provide you with the following important
information:
- How we may use and disclose your PHI
- Your privacy rights in your PHI
- Our obligations concerning the use and
disclosure of your PHI
The terms of this notice apply to all records
containing your PHI that are created or retained by
our practice. We reserve the right to revise or
amend this Notice of Privacy Practices. Any revision
or amendment to this notice will be effective for
all your records that our practice has created or
maintained in the past, and for any of your records
that we may create or maintain in the future. Our
practice will post a copy of our current Notice in
our offices in a visible location at all times, and
you may request a copy of our most current Notice at
any time.
B. If you have any questions about this
Notice, please contact:
Our practice’s Privacy Officer at 847-869-7777.
C. We may use and disclose your
individually identifiable protected health
information (pHI) in the following ways:
- Treatment. Our practice may use your
PHI to treat you. For example, we may ask you to
have laboratory tests (such as blood or urine
tests), and we may use the results to help us
reach a diagnosis. We might use your PHI in order
to write a prescription for you, or we might
disclose your PHI to a pharmacy when we order a
prescription for you. Many of the people who work
for our practice – including, but not limited to,
our doctors and nurses – may use and disclose your
PHI in order to treat you or to assist others in
your treatment. Additionally, we may disclose your
PHI to others who may assist in your care, such as
your partner or spouse, children, or parents.
Finally, we may also disclose your PHI to other
health care providers for purposes related to your
treatment.
- Payment. Our Practice may use and
disclose your PHI in order to bill and collect
payment for the services and items you may receive
from us. For example, we may contact your health
insurer to certify that you are eligible for
benefits (and for what range of benefits), and we
may provide your insurer with details regarding
your treatment to determine if your insurer will
cover, or pay for, your treatment. We also may use
your PHI to obtain payment from third parties that
may be responsible for such costs, such as family
members. Also, we may use your PHI to bill you
directly for services and items. We may disclose
your PHI to other health care providers and
entities to assist in their billing and collection
efforts.
- Health Care Operations. Our practice
may use and disclose your PHI to operate our
business. As examples of the ways in which we may
use and disclose your information for our
operations, our practice may use your PHI to
evaluate the quality of care you receive from us,
or to conduct cost-management and business
planning activities of our practice. We may
disclose your PHI to other health care providers
and entities to assist in their health care
operations.
- Treatment Options. Our practice may use
and disclose your PHI to inform you of potential
treatment options or alternatives. For example, if
new reproductive technologies or medical treatment
becomes available on our specialty.
- Health Related Benefits and Services.
Our practice may use and disclose your PHI to
inform you of health related benefits or services
that may be of interest to you. This may include
ancillary services, support groups or seminars.
- Disclosures Required By Law. Our
practice will use and disclose your PHI when we
are required to do so by federal, state and/or
local law.
D. Use and disclosure of your PHI in
certain special circumstances
The following categories describe unique
scenarios in which we may use and disclose your
individually identifiable health information (PHI):
- Public Health Risks. Our practice may
disclose your PHI to public health authorities
that are authorized by law to collect information
for the purpose of preventing or controlling
disease, injury or disability. We may disclose
your PHI, as required by law, to (a) a person who
may have been exposed to a communicable disease or
may otherwise be at risk of contracting or
spreading the disease or condition; (b) report
reactions to drugs or problems with drugs or
devices; (c) notify individuals if a product or
device that they may be using has been recalled;
(d) notifying appropriate government agencies and
authorities regarding the potential abuse or
neglect of an adult patient (including domestic
violence, although we will only disclose this
information if the patient agrees or we are
required or authorized by law to disclose this
information); (e) maintaining vital records such
as birth and death records; (f) reporting child
abuse or neglect; and (g) notifying your employer
under limited circumstances related primarily to
workplace injury or medical surveillance. We may
also disclose your PHI, if directed by a public
health authority, to a foreign government agency
that is collaborating with the public health
authority.
- Health Oversight Activities. Our
practice may disclose your PHI to a health
oversight agency for activities authorized by law.
Oversight activities can include, for example,
investigations, inspections, audits, surveys,
licensure and disciplinary actions; civil,
administrative, and criminal procedures or
actions; or other activities necessary for the
government to monitor government programs,
compliance with civil rights laws and the health
care system in general.
- Lawsuits and Similar Proceedings. Our
practice may use and disclose your PHI in response
to a court or administrative order, if you are
involved in a lawsuit or similar proceeding. We
also may disclose your PHI in response to a
discovery request, subpoena, or other lawful
process by another party involved in the dispute,
but only if we have made an effort to inform you
of the request or to obtain an order protecting
the information the party has requested.
- Law Enforcement. We may release PHI if asked
to do so by a law enforcement official:
- Concerning a death we believe resulted from
criminal conduct.
- Regarding criminal conduct at any of our
offices.
- In response to a warrant, summons, court,
order, subpoena or similar legal process.
- To identify/locate a suspect, material
witness, fugitive or missing person.
- In an emergency, to report a crime
(including the location or victim(s) of the
crime, or the description, identity or location
of the perpetrator).
- Research. Our practice may use and
disclose your PHI for research purposes in certain
limited circumstances. We will obtain your written
authorization to use your PHI for research
purposes except when an Internal Review Board or
Privacy Board has determine that the waiver of
your authorization satisfies the following: (a)
the use or disclosure involves no more than a
minimal risk to your privacy based on (i) an
adequate plan to protect the identifiers from
improper use and disclosure; (ii) an adequate plan
to destroy the identifiers at the earliest
opportunity consistent with the research (unless
there is a health or research justification for
retaining the identifiers or such retention is
other wise required by law); and (iii) adequate
written assurances that the PHI will not be reused
or disclosed to any other person or entity (except
as required by law) for authorized oversight of
the research study, or for other research for
which the use or disclosure would otherwise be
permitted; (b) the research could not practicably
be conducted without the waiver; and (c) the
research could not practicably be conducted
without access and use of PHI.
- Serious Threats to Health or Safety.
Our practice may use and disclose your PHI when
necessary to reduce or prevent a serious threat to
your health and safety, or the health and safety
of another individual or the public. Under these
circumstances, we will only make disclosures to a
person or organization able to help prevent the
threat.
- Military. Our practice may disclose
your PHI if you are a member of the U.S. or
foreign military forces (including veterans) and
if required by appropriate authorities.
- National Security. Our practice may
disclose your PHI to federal officials for
intelligence and national security activities and
authorized by law. We may also disclose your PHI
to federal officials in order to protect the
President, other officials or foreign heads of
state, or to conduct investigations.
- Inmates. Our practice may disclose your
PHI to correctional institutions or law
enforcement officials if you are an inmate or
under the custody of a law enforcement official.
Disclosure for these purposes would be necessary:
(a) for the institution to provide health care
services to you, (b) for the safety and security
of the institution, and/or (c) to protect your
health and safety or the health and safety of
other individuals.
- Workers’ Compensation. Our practice may
disclose your PHI for workers’ compensation and
similar programs.
E. Your Rights Regarding Your PHI
You have the following rights regarding the PHI
that we maintain about you:
Confidential Communications. You have the
right to request that our practice communicate with
you about your health and related issues in a
particular manner or at a certain location. For
instance, you may ask that we contact you at home
rather than at work. In order to request a type of
confidential communication, you must make a written
request to the Privacy Officer at 847-869-7777
specifying the requested method of contact, or the
location where you wish to be contacted. Our
practice will accommodate reasonable requests. You
do not need to give a reason for your request.
Requesting Restrictions. You have the
right to request a restriction in our use or
disclosure of your PHI for treatment, payment or
health care operations. Additionally, you have the
right to request that we restrict our disclosure of
your PHI to only certain individuals involved in
your care, or the payment of your care, such as
family members and friends. We are not required to
agree to your request; however, if we do agree, we
are bound by our agreement except when otherwise
required by law, in emergencies, or when the
information is necessary to treat you. In order to
request a restriction in our use or disclosure of
your PHI, you must make a written request to the
Privacy Officer at 847-869-7777. Your request must
describe in a clear and concise fashion (a) the
information you wish restricted; (b) whether you are
requesting to limit our practice’s use, disclosure
or both; and (c) to whom you want the limits to
apply.
Inspection and Copies. You have the right
to inspect and obtain a copy of your PHI that may be
used to make decisions about you, including patient
medical records and billing records, but not
including psychotherapy notes. You must submit your
request in writing to the Privacy Officer at
847-869-7777 in order to inspect and/or obtain a
copy of your PHI. Our practice may charge a fee for
the costs of copying, mailing, labor and supplies
associated with your request. Our practice may deny
your request to inspect an/or copy in limited
circumstance; however, you may request a review of
our denial. Another licensed health care
professional chosen by us will conduct reviews.
Amendment. You may ask us to amend your
PHI if you believe it is incorrect or incomplete,
and you may request an amendment for as long as the
information is kept by or for our practice. To
request an amendment you must make a written request
to the Privacy Officer at 847-869-7777. You must
provide us with a reason that supports your request
for amendment. Our practice will deny your request
if you fail to submit your request (and the reason
supporting your request) in writing. Also, we may
deny your request if you ask us to amend information
that is in our opinion; (a) accurate and complete;
(b) not part of the PHI kept by or for the practice;
(c) not part of the PHI which you would be permitted
to inspect or copy; or (d) not created by our
practice, unless the individual or entity that
created the information is not available to amend
the information.
Accounting of Disclosures. All of our
patients have a right to request and “accounting of
disclosures.” An “accounting of disclosures“ is a
list of certain non-routine disclosures our practice
has made of your PHI for non-treatment, non-payment
or non-operational purposes. Use of your PHI as part
of the routine patient care in our practice is not
required to be documented. For example, the doctor
sharing information with the nurse; or the billing
department using your information to file your
insurance claim. In order to obtain an accounting of
disclosures, you must make a written request to the
Privacy Officer at 847-869-7777. All requests for an
“accounting of disclosures” must state a time
period, which may not be longer that six (6) years
from the date of the disclosure and may not include
dates before April 14, 2003. The first list you
request within a 12-month period is free of charge,
but our practice may charge your for additional
lists within the same 12-month period. Our practice
will notify you of the costs involved with
additional requests, and you may withdraw your
request before you incur any costs.
Right to a Paper Copy of This Notice. You
are entitled to receive a paper copy of our Notice
of Privacy Practices. You may ask us to give you a
copy of this notice at any time. To obtain a copy of
this notice, contact to the Privacy Officer at
847-869-7777.
Right to File a Complaint. If you believe
your privacy rights have been violated, you may file
a complaint with our practice or with the Secretary
of the Department of Health and Human Services. To
file a complaint with our practice, contact the
Privacy Officer at 847-869-7777. All complaints must
be submitted in writing. You will not be penalized
for filing a complaint.
Right to Provide and Authorization for Other
Uses and Disclosures. Our practice will obtain
your written authorization for uses and disclosures
that are not identified by this notice or permitted
by applicable law. Any authorization you provide to
us regarding the use and disclosure of your PHI may
be revoked at any time in writing. After you
revoke your authorization, we will no longer use or
disclose your PHI for the reasons described in the
authorization. Please note, we are required to
retain records of your care.
If you have any questions regarding this notice
or our health information privacy practice, please
contact the Privacy Officer at 847-869-7777.
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