This Notice is effective April 13, 2003.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Our Commitment to Your Privacy: Our practice is dedicated to maintain the privacy of your individually identifiable health information (IIHI), also called Protected Health Information (PHI). 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 practice's legal duties and privacy practices with respect to protected health information. 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 must provide you with the following important information:
o How we may use and disclose your PHI.
o Your privacy rights in your PHI.
o 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 received and retained by our practice. This includes, but is not limited to demographic information such as name, address, age, social security number, or other information that identifies or can be used to identify an individual. We reserve the right to revise or amend this Notice whenever there is a material change to the uses or disclosures, the individual's rights, the covered entity's legal duties, or other privacy practices stated in the Notice. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is reflected. Any revision or amendment to this notice will be effective for all of 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. It is available to all patients, including those who have received a previous Notice. You may request a copy of our most current Notice at any time.
Documentation of Provision of Notice: When a direct treatment patient receives the Notice from the practice, the practice asks the patient to sign its "Receipt of Notice of Privacy Practices" form. The form is filed with the patient's medical record. If the patient refuses to sign the form, it is noted in the medical record that the patient was given the Notice and refused to sign the form.
Contact Person: The practice has a privacy officer that serves as the contact person for all issues related to the Privacy Rule. If you have any questions about this Notice, please contact Kerry Fleming, Privacy Officer at (847) 277 1440, 1410 South Barrington Road, Barrington, IL 60010
USES AND DISCLOSURES OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
The practice reasonably ensures that the individually identifiable health information (IIHI) also called Protected Health Information (PHI) it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose. The practice treats all qualified individuals as personal representatives of patients. The practice generally allows individuals to act as personal representatives of patients. Illinois law prohibits disclosure when 1) a minor is emancipated, 2) a minor is married, a parent, or pregnant, 3) a minor, aged 12 or over, is seeking treatment for birth control services or seeking treatment for alcoholism, drug use, sexually transmitted diseases, or in a family in which any family member abuses the minor, or 4) a minor, aged 12 or over, is seeking treatment for mental health or other developmental disabilities and prohibits disclosure. In addition, in Illinois, a specific written authorization is required to disclose or release mental health treatment, genetic information, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information even for treatment. The practice makes reasonable efforts to ensure that protected health information is only used by and disclosed to individuals that have a right to the protected health information. Toward that end, that practice makes reasonable efforts to verify the identity of those using or receiving protected health information.
THE FOLLOWING CATEGORIES DESCRIBE THE DIFFERENT WAYS IN WHICH WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.
The practice uses and discloses protected health information for payment, treatment, and health care operations.
1. Treatment includes those activities related to providing services to the patient, including releasing information to other health care providers involved in the patient's care. For example, we may ask you to have laboratory 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 you PHI to a pharmacy when we order a prescription for you. Your doctor, nurse or staff may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI with your approval to others who may assist in your care, such as your spouse, children or parents, or when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of the practice. When the patient is not present, the practice determines whether the disclosure of the patient's protected health information is authorized by law and if so, discloses only the information directly relevant to the person's involvement with the patient's health care.
The practice does not disclose protected health information to a suspected abuser, if, in its professional judgment, there is reason to believe that such a disclosure could cause the patient serious harm. Further, the practice uses and discloses information as required by law. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.
The practice does not disclose protected health information that has to do with mental health treatment, genetic information, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS), even for treatment, unless there is a specific written authorization to disclose or release that information.
2. Payment relates to all activities associated with getting reimbursed for services and items you may receive from us, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. 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 may also use and disclose 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.
3. Health care operations include a number of areas. Our practice may use and disclose your PHI to operate our business. As examples of the way 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 received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations, including quality assurance and peer review activities.
4. Uses and Disclosures in Emergency Situations. The practice uses and discloses protected health information as appropriate to provide treatment in emergency situations. In those instances where the practice has not previously provided its Notice of Privacy Practices to a patient who receives direct treatment in an emergency situation, the practice provides the Notice to the individual as soon as practicable following the provision of the emergency treatment.
5. Appointment Reminders, Treatment Options and Health-Related Benefits and Services. Our practice may use and disclose your PHI to contact you with appointment reminders or to inform you about treatment alternatives or other heath-related benefits and services that may be of interest to you.
6. Research. The 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 Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: : (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) 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 otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used 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; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
The practice discloses only the information directly relevant to the research activity when such disclosures are deemed appropriate in the professional judgment of the practice.
7. Marketing Purposes. Our practice may use and disclose your PHI to engage in communications about products and services that encourages recipients of the communication to purchase or use a product or service for treatment. We will obtain your written authorization to use your PHI for marketing purposes.
8. Uses and Disclosures Required by Law. The practice uses and discloses protected health information to appropriate individuals as required by federal, state and local law.
9. Workers' Compensation. Our practice may release your PHI for workers' compensation and similar programs as required by law. We will obtain your written authorization to release your PHI to employer for payment of workers' compensation claim, that we have been directed to bill to employer directly.
10. Third Party Liability Insurance. Automobile insurance, homeowners insurance, and similar policies that provide coverage for health care expenditures in most circumstances are not covered under HIPAA. We will obtain your written authorization to release your PHI to such entities.
11. Lawsuit 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 may also 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.
USES AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES:
1. Public Health Risks. As required by law the practice discloses protected health information to public health officials. This includes reporting of communicable diseases and other conditions, sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated reports of injury, medical conditions or procedures, or food-borne illness including but not limited to adverse reactions to immunizations, cancer, adverse pregnancy outcomes, death, birth.
The practice discloses protected health information regarding victims of abuse, neglect, or domestic violence. The practice discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse.
The practice informs the individual of the reporting unless the practice, in the exercise of professional judgment, believes informing the individual would place the individual at risk of serious harm or the practice would be informing a personal representative, and the practice believes the personal representative is responsible for the abuse, neglect, or other injury, and that informing such person would not be in the best interests of the individual as determined by the professional judgment of the practice.
Health Oversight Activities: The practice uses and discloses PHI as required by law for health oversight activities. The information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but limited to hospital peer review, managed care peer review, or Medicaid or Medicare peer review. In general, the practice discloses information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal.
Law Enforcement Purposes: The practice discloses PHI for law enforcement purposes to law enforcement officials. Deceased Patients: The practice may discloses PHI as required to a coroner or medical examiner and funeral directors as required by law.
Organ and Tissue Donation: The practice uses and discloses protected health information to facilitate organ, eye or tissue donations, if you are an organ donor.
Serious Threat to Health or Safety: The practice uses and discloses protected health information to public health and other authorities as required by law to avert a serious threat to health or safety.
Specialized Government Functions: The practice uses and discloses protected health information for military and veterans activities, national security and intelligence activities, and other activities as required by law.
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.
Other Uses and Disclosures: The practice does not use or disclose protected health information to an employer or health plan sponsor, for underwriting and related purposes, for facility directories, to brokers and agents, or for fundraising. If an individual wants the practice to release his or her protected health information to employers or health plan sponsors, for underwriting and related purposes, for facility directories, or to brokers and agents, then he or she can contact the practice and complete an appropriate written authorization.
INDIVIDUAL RIGHTS
YOU HAVE THE FOLLOWING RIGHTS REGARDING THE PHI THAT WE MAINTAIN ABOUT YOU:
1. 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 that work. A request for confidential communications must be in writing to Attn: Privacy Officer, Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Barrington, IL 60010. It must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the practice's privacy officer. No reason for the request needs to be stated. Our practice will accommodate all reasonable requests. The reasonableness of a request is determined solely on the basis of the administrative difficulty of complying with the request. The practice will reject a request due to administrative difficulty: if no independently verifiable method of communication such as a mailing address or published telephone number is provided for communications, including billing; or if the requestor has not provided information as to how payment will be handled. The practice will not refuse a request: if the requestor indicates that the communication will cause endangerment; or based on any perception of the merits of the requestor's request.
2. Request Restriction of Disclosures. 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 for your care, such as family members and friends. The practice accepts all requests for restrictions of disclosures of protected health information. 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. All requests for restrictions of disclosures must be submitted in writing to Attn: Privacy Officer, Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Barrington, IL 60010. 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. The privacy officer notifies the requestor in writing whether the practice accepts the request for restrictions.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the 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 Attn:, Privacy Officer, Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Suite 1, Barrington, IL 60010, in order to inspect and/or obtain a copy of your PHI. For further information call our Privacy Officer at (847) 277-1440. The practice documents all requests, reviews the request in a timely fashion and acts on a request for access generally within 30 days. The practice may have a single extension of 30 days, if needed to act on the request. Each request will be accepted or denied and the requestor notified in writing. The practice informs individuals of their appeal rights when a request is rejected in whole or in part. If a request is denied, the requestor is informed if the denial is "reviewable" or not. The requestor has the right to have any denial reviewed by a licensed health care professional who is designated by the practice as a reviewing official and who did not participate in the original decision to deny. The practice informs the requestor of the decision of the reviewing official and adheres to the decision. The practice charges reasonable fees based on actual cost of fulfilling the request. The practice will determine the appropriate charge for providing the requested records and inform the requestor in advance of providing the records. If the requestor agrees to pay the fee in advance the records will be provided. Otherwise, the records will not be provided, unless the Privacy Officer determines that the charge is burdensome to the requestor. Illinois law prohibits charges that exceed the following: $20.48 handling fee plus 77 cents each for pages 1-25, 51 cents each for pages 26-50, and 26 cents each for pages 51 to end; plus actual expenses related to the copying of x-rays, CAT scans, and similar. The practice limits charges for records to the amounts allowed under Illinois law.
4. Amendment to Protected Health Information. You may ask us to amend the protected health information maintained in the patient's medical record or the patient's billing record, 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, your request must be made in writing and submitted to Attn: Privacy Officer, Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Suite 1, Barrington, IL 60010. You must provide us with a reason that supports your request for amendment. The practice documents all requests, responds to those requests in a timely fashion, and informs individuals of their appeal rights when a request is denied in whole or in part. 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 and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
Generally the practice will act on a request for amendment no later than 60 days after receipt of such a request. If the practice cannot act on the amendment within 60 days, the practice extends the time for such action by 30 days and, within the 60-day time limit, provides the requestor with a written statement of the reasons for the delay and the date by which the practice will complete action on the request. Only one such extension is allowed.
If the practice denies the request, in whole or in part, the practice provides the requestor with a written denial in a timely fashion. The practice allows a requestor to submit a written statement disagreeing with the denial of all or part of the initial request. The statement must include the basis of the disagreement. The practice limits the length of a statement of disagreement to one page. For further information you may contact our Privacy Officer at (847) 277-1440.
5. Accounting of Disclosures. The practice tracks all disclosures of a patient's protected health information that occur for other than the purposes of treatment, payment, and health care operations, that are not made to the individual or to a person involved in the patient's care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials. All of our patients have the right to request an "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-operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, 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 submit your request in writing to Attn: Privacy Officer, Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Suite 1, Barrington, IL 60010. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The practice allows an individual to request one accounting within a 12-month period free of charge. The practice charges a reasonable fee for more frequent accounting requests. The charge will be $25.00. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. The practice responds to all requests for an accounting of disclosures within 60 days of receipt of the request. If the practice intends to provide the accounting for disclosures and cannot do so within 60 days, the practice informs the requestor of such and provides a reason for the delay and the date the request is expected to be fulfilled. Only one 30-day extension is permitted.
6. Right to File a Complaint. A patient or his or her agent may file a complaint with the practice or with the Secretary of the Department of Health and Human Services (DHHS), whenever he or she believes that the practice has violated their rights. Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of the practice's privacy officer at Midwest Plastic Surgery Specialists, 1410 South Barrington Road, Suite 1, Barrington, IL 60010. The practice investigates each complaint and may, at its discretion, reply to the patient or the patient's agent. All complaints must be submitted in writing. The practice does not take any adverse action against any patient who files a complaint (either directly or through an agent) against the practice. Complaints to the Secretary of the Department of Health and Human Services must be in writing, must name the practice, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to: Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Chicago, IL 60601, Voice Phone (312) 886-2359, FAX (312) 886-1807, TDD (312)353-5693.
7. Right to Provide an 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.
The practice obtains a written authorization from a patient or the patient's representative for the use or disclosure of protected health information for other than treatment, payment, or health care operations; however, the practice will not get an authorization for the use or disclosure of protected health information specifically allowed under the Privacy Rule in the absence of an authorization. The practice will provide a patient upon request a copy of any authorization initiated by the practice (as opposed to requested by the patient) and signed by the patient.
The practice does not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for purpose of creating protected health information for disclosure to a third party (e.g., pre-employment or life insurance physicals).
In Illinois, a specific written authorization is required to disclose or release of mental health treatment, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information.
Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time. The revocation must be in writing and must be sent to the attention of the practice's privacy officer; however, in any case the practice will be able to use or disclose the protected health information to the extent practice has taken action in reliance on previous authorization. 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.
8. 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 paper copy of this notice and for further information, contact Privacy Officer, Midwest Plastic Surgery Specialists, Telephone (847) 277-1440
9. Waiver of Rights. The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law.
Again, if you have any questions regarding this notice or our health information privacy policies, please contact Privacy Officer, Midwest Plastic Surgery Specialists, Telephone (847) 277-1440.