THIS NOTICE DESCRIBES HOW CONFIDENTIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We respect patient confidentiality and only release confidential information about you in accordance with the Illinois and federal law. This notice describes our policies related to the use of the records of your care generated by this practice.
Privacy Contact: If you have any questions about this policy or your rights, contact our Privacy Officers, The HIPAA Committee at (773) 252-3100.
Use and Disclosure of Protected Health Information
In order to effectively provide you care, there are times when we will need to share your confidential information with others beyond our agency. This includes for:
Treatment We may use or disclose treatment information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside our agency that we are consulting with or referring you to.
Payment With your written consent, information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes.
Healthcare Operations We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.
Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:
Emergencies Sufficient information may be shared to address the immediate emergency you are facing.
Follow Up Appointments/Care We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We will leave appointment information on your answering machine unless you tell us not to.
As Required by Law This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.
Coroners We are required to disclose information about the circumstances of your death to a coroner who is investigating it.
Governmental Requirements We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. We are also required to share information, if requested with the United States Department of Health and Human Services to determine our compliance with federal laws related to health care and to any State or municipal funding agency that is involved with your treatment.
Criminal Activity or Danger to Others If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.
Fund-raising As a not-for-profit provider of health care services, we need assistance in raising money to carry out our mission. We may contact you to seek a donation.
You have the following rights under Illinois and federal law:
Copy of Record You have the right to view the record that our agency has generated about you. A copy of your record must be made available to you within 30 days of your request. There will be a fee for copying and mailing your record.
Release of Records You may consent in writing to the release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.
Restriction on Record You may ask us not to use or disclose part of the clinical information. This request must be in writing. The agency is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information. The request should be given to the Privacy Contact previously indicated on this form.
Contacting You You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. We also will be glad to provide you information by email if you request it.
Amending Record If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this contact the Privacy Contact and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment, you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.
Accounting for Disclosures You may request an accounting of any disclosures we have made related to your confidential information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period, no longer than six years, please submit your request in writing to our Privacy Contact. We will notify you of the cost involved in preparing this list.
Questions and Complaints If you have any questions, or wish a copy of this Policy or have any complaints you may contact our Privacy Contact in writing at our office for further information. You also may complain to the Secretary of United States Department of Health and Human Services if you believe our agency has violated your privacy rights. We will not retaliate against you for filing a complaint.
If you feel your rights have been violated and the issue has not been addressed to your satisfaction, you may pursue your grievance with the following agencies:
Department of Human Services, Office of Alcoholism and Substance Abuse, 160 N. LaSalle, Chicago, IL 60601 (312) 814-3840
The Guardianship and Mental Health Advocacy Commission, 160 N. LaSalle, Chicago, IL. 60601 (312) 793 -5900
Equip for Equality, 11 E. Adams, Suite 1200, Chicago, IL 60603 (312) 341-0022 or 1-800-537-2632
Office for Civil Rights, U.S. Department of Health & Human Services, 233 N. Michigan Ave. – Suite 240, Chicago, IL 60601, (312) 886-2359; (312) 353-5693 (TDD) (312) 886-1807 FAX