NOTICE OF PROTECTED HEALTH INFORMATION PRACTICES AND PRIVACY STATEMENT
HIPAA Privacy Notice
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.
Who We Are
This Notice describes the privacy practices of Orsini Healthcare and its affiliates.
Our Privacy Obligations
As part of the American Recovery and Reinvestment Act of 2009, the HITECH Act is law that in conjunction with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191)protects the patient from improper
release or use of Protected Health Information (PHI).The Office for Civil Rights enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety.
Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
Uses and Disclosures for Treatment, Payment and Healthcare Operations
We may use and disclose PHI, but not your "Highly Confidential Information" (defined in Section IV. C below), in order to treat you, obtain payment for equipment and services provided to you and conduct our "healthcare operations" as detailed below:
Treatment We use and disclose your PHI to provide treatment and other services to you -- for example, to treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health- related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
Payment We may use and disclose your PHI to obtain payment for equipment and services that we provide to you -- for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your healthcare ("Your Payors") to verify that Your Payors will pay for healthcare rendered.
Healthcare Operations We may use and disclose your PHI for our healthcare operations, which include internal
administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our respiratory therapists, nurses and other healthcare workers. We may also disclose PHI to your other healthcare providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain healthcare operations, such as quality assessment and improvement activities, reviewing the quality and competence of healthcare professionals, or for healthcare fraud and abuse detection or compliance.
Disclosure to Relatives, Close Friends and Other Caregivers
We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the public's involvement with your healthcare or payment related to your healthcare. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
Public Health Activities
We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U. S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work- related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect or Domestic Violence
If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities
We may disclose your PHI to a health oversight agency that oversees the healthcare system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings
We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Officials
We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
We may disclose your PHI to a coroner or medical examiner as authorized by law.
Organ and Tissue Procurement
We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
We may use or disclose your PHI without your consent or authorization if an Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.
Health or Safety
We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.
Specialized Government Functions
We may use and disclose your PHI to units of the government with special functions, such as the U. S. military or the U. S. Department of State under certain circumstances.
We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs.
As Required by Law
We may use and disclose your PHI when required to do so by any other law not with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not already referred to in the preceding categories.
Uses and Disclosures Requiring Your Written Authorization
Use or Disclosure with Your Authorization
For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization ("Your Authorization"). For instance, you will need to execute an authorization before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
We must also obtain your written authorization ("Your Marketing Authorization") prior to using your PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining Your Marketing Authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.) In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.
Uses and Disclosures of Your Highly Confidential Information
In addition, federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"). We will comply with such special privacy protections which may cover the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/ AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; (9) is about sexual assault; or (10) is about abortion.
Your Rights Regarding Your Protected Health Information
For Further Information, Complaints
If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact Patient Relations. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, Patient Relations will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
Right to Request Restrictions
You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and healthcare operations; (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction, except that in certain instances we must agree to a restriction relating to a disclosure to a health plan for the purposes of carrying out payment or healthcare operations in which the PHI pertains solely to a healthcare item or service for which the healthcare provider involved has already been paid out of pocket in full. If you wish to request restrictions, please submit a written request to Patient Relations. A form to request restrictions is available upon request from Patient Relations.
Right to Receive Confidential Communications
You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Right to Revoke Your Authorization
You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to Patient Relations identified below. A form of written revocation is available upon request from Patient Relations.
Right to Inspect and Copy Your Health Information
You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. There is a fee for obtaining copies of your records that is consistent with the Illinois State Comptrollers fees for making copies. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please submit a written request to us at
ATTN: Patient Relations
1111 Nicholas Boulevard
Elk Grove Village, IL 60030
or download a copy of our HIPAA release form and either fax it to (847-734-1822) or scan and email it to email@example.com.
For fees related to copies requested please visit the State Comptrollers website at http://www.ioc.state.il.us/office/fees.cfm.
Right to Amend Your Records
You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please send a written request for the amendment, including the reason for the amendment, to Patient Relations. You may obtain a form to request an amendment from Patient Relations. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive an Accounting of Disclosures
Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.
Right to Receive Paper Copy of This Notice
Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
Effective Date and Duration of This Notice
This Notice is effective as of January 1, 2011
Right to Change Terms of This Notice
We reserve the right to, meaning we may, change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas at our facility and on our Internet site. You also may obtain any new notice by contacting Patient Relations.
You may contact Patient Relations at
ATTN: Patient Relations
1111 Nicholas Blvd.
Elk Grove Village Illinois 60007-5216
Phone: (800) 672-0869
Fax: (847) 734-1822