This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact our Privacy Contact, Dale Hayes
St Charles Plastic Surgery is required by law to maintain the privacy of confidential information. The practice is required to abide by the terms of the Notice currently in effect; however, we reserve the right to change the terms of the Notice and to make the new provisions effective for all confidential information that it maintains. The revised Notice will be displayed in the office for your review. Upon your request, a revised copy will be mailed to you.
The confidentiality of your personal health information is important to us. As physicians, we rely on you to provide us with complete and accurate information about your condition, symptoms, and health history, which help us to provide your care and treatment. We appreciate that you trust us with this personal information. We want you to know about the privacy practices in our office that are intended to safeguard the proper use and disclosure of your Protected Health Information.
We want you to know about HIPAA’s privacy rule and the terms used in our Notice of Privacy Practices.
“HIPAA” stands for the Health Insurance Portability and Accountability Act. On August 14, 2002, the Department of Health and Human Services issued the HIPAA Privacy Rule, which describes how Protected Health Information may be properly Used and Disclosed.
“Protected Health Information” means information about you, including your past, present, and future medical condition, treatment of your medical condition, and payment for your medical treatment. This information includes demographic information that may identify you.
“Use” means how we (physicians and staff) properly share, employ, examine, utilize or analyze Protected Health Information internally within our office.
“Disclose” means how we (physicians and staff) properly release, transfer, divulge or provide access to Protected Health Information to an outside person or entity such as another doctor, hospital, or insurance company.
“Designated Record Set” means medical and billing records created and maintained by our office for treatment and payment.
We want you to know about our privacy practices for use and disclosure of Protected Health Information based upon your consent
You will be asked to sign a consent form regarding the use and disclosure of your Protected Health Information.
As permitted by the HIPAA’s Privacy Rule, we will use and disclose Protected Health Information for the purposes of providing health care services to you, acquiring payment for your health care bills, and providing support to the operations of the physician’s practice.
Following are examples of the types of uses and disclosures of your Protected Health Information that the physician’s office is permitted to make. These are not meant to be exhaustive, but to describe the types of uses and disclosures that may occur.
Treatment: We will use Protected Health information to provide, coordinate, or manage your health care. For example, your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. We will also disclose Protected Health Information to other health care providers, hospitals, and facilities that are involved in providing or coordinating your treatment.
Payment: We will use Protected Health Information, as needed, to obtain payment for health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, medical necessity, pre-certification requirements, and undertaking utilization review activities. In addition, we will disclose your Protected Health Information when we submit a claim to your health plan for payment of treatment we provided you.
Healthcare Operations: We will use or disclose, as needed, your Protected Health Information to support business activities of the physician’s practice. For example, we may call you by name in the reception area when the physician is ready to see you. We may use your Protected Health Information to contact you to remind you of your appointment. Your name and address may be used to send you a newsletter about our practice services. We may use your Protected Health Information for internal auditing and quality assessment activities.
We may use or disclose your Protected Health Information, as necessary, with third party “business associates” that perform various activities (e.g. collections agencies, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your Protected Health Information, we will have a written contract that contains terms that will protect the privacy of your Protected Health Information.
We want you to know our privacy practices for use and disclosure of Protected Health Information based upon written authorization and your right to revoke in writing that authorization.
We will not use or disclose your Protected Health Information for purposes other than treatment, payment or health care operations, unless permitted or required by law, without your signed, written authorization. For example, we will not release records to your employer for employment purposes without obtaining your written authorization. We will not disclose Protected Health Information to a third party for marketing purposes without your written authorization.
It is important to note that once information is provided (with your written authorization) to a person or entity that is not required to comply with HIPAA’s Privacy Rule for the use or disclosure of Protected Health Information, the information is no longer considered Protected Health Information and is not covered under the HIPAA’s Privacy Rule.
You may revoke an authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken action in reliance on the use or disclosure indicated in the authorization.
Other permitted and required uses and disclosures that may be made with your consent, authorization or opportunity to object.
We may use and disclose your Protected health Information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your Protected Health Information. If you are not present or able to agree to object to the use or disclosure of the Protected Health Information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only Protected Health Information that is relevant to your health will be disclosed.
Others involved in you care: Unless you object, we may disclose to a member of your family, a relative, close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose Protected Health Information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your Protected Health Information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family and other individuals involved in your health care.
Emergencies: We may use or disclose your Protected Health Information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician has attempted to obtain your consent but is unable to obtain your consent, he may still use or disclose your Protected Health Information to treat you.
Communication barriers: We may use and disclose your Protected Health Information if your physician attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
We want you to know our privacy practices for use and disclosure of Protected Health Information that may be made without your consent, authorization or opportunity to object.
We may use or disclose your Protected Health Information in the following situations without your consent or authorization. These situations include:
Required by law: The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by the law, of any such uses or disclosures.
Public Health: We may disclose your Protected Health Information to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability.
Communicable diseases: We may disclose Protected Health Information, if authorized by law, to 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.
Health oversight: We may disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigation, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil right laws.
Abuse or Neglect: We may disclose your Protected Health Information to public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your Protected Health Information if we believe that you have been a victim of abuse, neglect or domestic violence to the government agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.
Research: We may disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq
We want you to know your rights under the privacy rule and our privacy practices.
Your rights under HIPAA’s Privacy Rule and our privacy practices are very important to us. We want you to understand your rights, and how we may respond to your requests. Following is a statement of your rights with respect to your Protected Health Information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice may use for making decisions about you.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed.
You may request access to your Protected Health Information by completing the “Request for Access” form. Our practice is to consider all requests according to our legal responsibilities under the Privacy Rule. We will act on your request within 30 days from the time we receive the completed form. If we are able to grant your request, we will contact you to arrange a time for you to inspect your Protected Health Information.
Under the Privacy Rule, we may charge you copying costs (supplies and labor) and postage.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in caring for you.
You may request a restriction of your Protected Health Information by completing the “Request for Restriction” form.
It is important to note that HIPAA’s Privacy Rule gives all physicians the right to deny patient requests for restricted use or disclosure of Protected Information. While we will consider reasonable requests, it is our general policy and practice not to restrict the use or disclosure of Protected Health Information that is necessary for providing good treatment or important for protecting the health and safety of others providing treatment or taking care of you. Restricting disclosure could adversely affect the ability of a physician or provider to give you proper treatment.
It is our general policy and practice not to restrict the use or disclosure of Protected Health Information when submitting a claim to a health plan for reimbursement.
If you are a minor (less than 18 years old), you may request us not to disclose Protected Health Information to your parents. We will consider this request in connection with our obligations under Illinois law.
You have the right to request to receive confidential communication from us by alternative means or at an alternative location. Our general policy is to contact you by telephone at your home telephone number or by mail at your home address. If we contact you by telephone, we simply will identify our office and ask to speak with you. We will leave a message with the person answering the phone or on your answering machine by identifying our office and telephone number and requesting you to return our call, but we will not disclose any details.
You have the right to request that we communicate with you confidentially by alternative means or at alternative locations. Our policy is to honor all reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request.
You have the right to amend incorrect or incomplete facts in your Protected Health Information maintained in a designated record set. You may request to amend your Protected Health Information by completing the “Request to amend” form. We will provide a written response to your written request within 30 days from the time we receive your completed form.
We will honor your request if Protected Health Information is incorrect or incomplete. We may not, under the HIPAA Privacy Rule, amend your Protected Health Information if it is not a part of a designated record set, if it would not be available for you to inspect, or if the information is accurate and complete.
For example, if your record mistakenly indicates that you received treatment for a fracture of the right arm when, in fact, your treatment was for a sprain of your left leg, clearly that information should be amended. If, however, you want to delete a reference contained in the history that you told the doctor that you were feeling “depressed”, it would not be appropriate to delete that reference from the Protected Health Information, because it accurately reflected the information you gave the doctor.
If we accept the requested amendment, we will: (1) amend the Protected Health Information in the designated record set; (2) inform you that we have made the amendment and; (3) notify persons who have received and may have relied on Protected Health Information that has been amended.
If we deny your request to amend Protected Health Information, we will: (1) notify you in writing of the basis for that denial; (2) inform you of your right to submit a written statement of disagreement which we will maintain with your record and will include with future disclosures, if requested; and (3) inform you of your right to file a complaint.
If you file a statement of disagreement, we may prepare a written rebuttal statement.
You have the right to receive an accounting of certain disclosures we have made, if any, of your Protected Health Information. This right is limited and does not require us to provide you with an accounting of disclosures for: (1) treatment, payment and healthcare operation purposes; (2) disclosures made to you or your legal representative on your behalf; (3) disclosures made in accordance with a written authorization that you signed; or (4) disclosures made before April 14, 2003. To request an accounting of disclosures, please complete the “Request for Accounting” form.
We want you to know about our concern and complaint resolution procedure.
We are committed to safeguarding your Protected Health Information. Despite our good faith efforts, questions, concerns and misunderstandings may arise.
If you have a concern or believe that we may have violated your Privacy rights, we encourage you to bring that to our attention.
You may voice your concern by calling 630-762-9697 and speaking with our privacy contact. If you prefer, you may submit a complaint in writing as well.
We take all concerns and complaints very seriously and will investigate each one promptly. If we made a mistake, we will do what we can to correct it and take steps to prevents mistakes in the future.
Under no circumstances will we “retaliate” against you for expressing a concern or filing a complaint relating to your Privacy rights.
You also have the right to contact the Department of Health and Human Services if you believe your privacy rights have been violated.
This notice was published and became effective on October 15, 2002.
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