NOTICE OF PRIVACY PRACTICES
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
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU
We are required by law to protect the privacy of medical information about you and that identifies you. This medical information may be information about health care we provide to you or payment for health care provided to you. It may also be information about your past, present, or future medical condition.
We are also required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose medical information in the manner that we have described in this Notice.
We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all medical information that we maintain. If we make changes to the Notice, we will:
- Post the new Notice in our waiting area.
- Have copies of the new Notice available upon request (you may always contact our Privacy Officer 847-657-7900 to obtain a copy of the current Notice).
The rest of this Notice will:
- Discuss how we may use and disclose medical information about you.
- Explain your rights with respect to medical information about you.
- Describe how and where you may file a privacy-related complaint.
If, at any time, you have questions about information in this Notice or about our privacy policies, procedures or practices, you can contact our Privacy Officer at 847-657-7900.
WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU IN SEVERAL CIRCUMSTANCES
We use and disclose medical information about patients every day. This section of our Notice explains in some detail how we may use and disclose medical information about you in order to provide health care, obtain payment for that health care, and operate our business efficiently. This section then briefly mentions several other circumstances in which we may use or disclose medical information about you. For more information about any of these uses or disclosures, or about any of our privacy policies, procedures or practices, contact our Privacy Officer at 847-657-7900.
Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made for the previous six (6) years. If you would like to receive an accounting, you may send us a letter requesting an accounting, fill out an Accounting Request Form, or contact our Privacy Officer. Accounting Request Forms are available from our Privacy Officer.
The accounting will not include several types of disclosures, including disclosures for treatment, payment or health care operations. If we maintain your medical records in an Electronic Health Record (EHR) system, you may request that include disclosures for treatment, payment or health care operations. The accounting will also not include disclosures made prior to April 14, 2003.
If you request an accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of preparing the accounting. Our Fee Structure is Supplied to Patients Separately Upon Request.
Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical information about you that we maintain in certain groups of records. If you believe that we have information that is either inaccurate or incomplete, we may amend the information to indicate the problem and notify others who have copies of the inaccurate or incomplete information. If you would like us to amend information, you must provide us with a request in writing and explain why you would like us to amend the information. You may either write us a letter requesting an amendment or fill out an Amendment Request Form. Amendment Request Forms are available from our Privacy Officer.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree with our decision to deny your amendment request and we will share your statement whenever we disclose the information in the future.
Right to Request an Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different method. For example, you may prefer to have all written information mailed to your work address rather than to your home address.
We will agree to any reasonable request for alternative methods of contact. If you would like to request an alternative method of contact, you must provide us with a request in writing. You may write us a letter or fill out an Alternative Contact Request Form. Alternative Contact Request Forms are available from our Privacy Officer.
Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of medical information about you that we maintain in certain groups of records. If we maintain your medical records in an Electronic Health Record (EHR) system, you may obtain an electronic copy of your medical records. You may also instruct us in writing to send an electronic copy of your medical records to a third party. If you would like to inspect or receive a copy of medical information about you, you must provide us with a request in writing. You may write us a letter requesting access or fill out an Access Request Form. Access Request Forms are available from our Privacy Officer.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in writing. We will also inform you in writing if you have the right to have our decision reviewed by another person.
If you would like a copy of the medical information about you, we may charge you a fee to cover the costs of the copy. Our fees for electronic copies of your medical records will be limited to the direct labor costs associated with fulfilling your request.
We may be able to provide you with a summary or explanation of the information. Contact our Privacy Officer for more information on these services and any possible additional fees.
Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of medical information about you for treatment, payment and health care operations. Under federal law, we must agree to your request and comply with your requested restriction(s) if:
- Except as otherwise required by law, the disclosure is to a health plan for purpose of carrying out payment of health care operations (and is not for purposes of carrying out treatment); and,
- The medical information pertains solely to a health care item or service for which the health care provided involved has been paid out-of-pocket in full.
Once we agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.
Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this Notice will always be posted in our waiting area. If you would like to have a copy of our Notice, ask the receptionist for a copy or contact our Privacy Officer at 847-657-7900.
You can download a pdf of this document here.
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a written complaint either with us or with the federal government.
We will not take any action against you or change our treatment of you in any way if you file a complaint.
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer, or you may mail it to the following address:
6449 Dempster St.
Morton Grove, IL 60053
To file a written complaint with the federal government, please use the following contact information:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Toll-Free Phone: (800) 368-1019
TDD Toll-Free: (800) 537-7697