Chicago Podiatric Surgeons,
PC
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
The
HIPPA Privacy Rule, a federal regulation, requires that we
provide detailed notice in writing of our privacy practices.
We recognize this is a lengthy document, however the rule
requires many specific issues to be addressed. We must follow
the privacy practices that are described in this notice while
it is in effect. This notice takes effect April 14, 2003,
and will remain in effect until we replace it.
We reserve
the right to change our privacy practices and the terms of
this notice at any time, provided that applicable law permits
such changes. We reserve the right to make the changes in
our privacy practices and the new terms of our notice effective
for all protected health information that we maintain, including
medical information we created or received before we made
the changes. A copy of our notice, or any subsequent revised
notice, may be requested at any time. For more information
about our privacy practices, please contact us using the
information listed at the end of this notice.
Uses and Disclosures
of Protected Health Information
We will use and disclose your protected health information
or "PHI" about
you for treatment, payment, and health care operations.
Following are examples of the types and uses of disclosures
of your PHI that may occur. These examples are not meant
to be exhaustive, but to describe the types of uses and disclosures
that may be made by our office.
TREATMENT: We will use and
disclose your PHI to provide, coordinate or manage your health
care and any related services. This includes the coordination
or management of your health care with a third party. For
example, we would disclose your PHI, as necessary, to a home
health agency that provides care to you. We would also disclose
PHI to other physicians who may be treating you. For example,
your PHI 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.
In addition, we may disclose your PHI from time to time to
another physician or health care provider (e.g., another
specialist, laboratory) who, at the request of your physician,
becomes involved in your care by providing assistance with
your health care diagnosis or treatment to your physician.
PAYMENT: Your PHI will be used, as needed,
to obtain payment for your 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, reviewing
services provided to you for protected health necessity,
and undertaking utilization review activities. For example,
obtaining approval for a surgical procedure may require that
your relevant PHI be disclosed to the health plan to obtain
approval for the surgical procedure.
HEALTH CARE OPERATIONS: We may use or disclose,
as needed, your PHI in order to conduct certain business
and operational activities. These activities include, but
are not limited to, quality assessment activities, employee
review activities, training of students, licensing, and conducting
or arranging for other business activities. For example,
we may use a sign-in sheet at the reception desk or we may
call you by name in the waiting room when your doctor is
ready to see you. We may use and disclose PHI, as necessary,
to contact you by telephone or mail to remind you of your
appointment.
We will share your PHI with third party Business
Associates that perform various activities (e.g., billing,
transcription services) for the practice. Whenever an arrangement
between or office and a Business Associate involves the uses
or disclosure of you PHI, we will have a written contract
that contains terms that will protect the privacy of you
PHI.
We may use or disclose your PHI, as necessary, to provide
you with treatment alternatives or other health-related benefits
and services that may be of interest to you. We may also
use and disclose your PHI for other marketing activities.
For example, your name and address may be used to send you
a newsletter about our practice and the services we offer.
We may also send you information about products or services
that we believe may be beneficial to you. You may contact
us to request that these materials not be sent to you.
USES
AND DISCLOSURES BASED ON YOUR WRITTEN AUTHORIZATION: Other
uses and disclosures of your PHI will me made only with your
authorization, unless otherwise permitted or required by
law as described below.
You may give us written authorization
to use your PHI or to disclose it to anyone for any purpose.
If you give us an authorization, you may revoke it in writing
at any time. Your revocation will not affect any use or disclosures
permitted by you authorization while it was in effect. Without
written authorization, we will not disclose you PHI except
as describe in this notice.
OTHERS INVOLVED IN YOUR HEALTH
CARE: Unless you object, we may disclose to a member
of your family, a relative, a close fried or any other person
you identify, your PHI 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
PHI 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.
MARKETING: We may use your PHI to contact
you with information about treatment alternatives that may
be of interest to you. We may disclose your PHI to a business
associate to assist us in these activities. Unless the information
is provided to you by a general newsletter or in person or
is for products or services of nominal value, you may opt
out of receiving further such information by telling us using
the contact information at the end of this notice.
RESEARCH;
DEATH; ORGAN DONATION: We may use or disclose your
PHI for research purposes in limited circumstances. We may
disclose the PHI of a deceased person to a coroner, protected
health examiner, funeral director or organ procurement organization
for certain purposes.
PUBLIC HEALTH AND SAFETY: We may disclose
your PHI to the extent necessary to avert a serious and imminent
threat to your health or safety, or the health or safety
of others. We may disclose your PHI to a governmental agency
authorized to oversee the health care system or governmental
programs or its contactors, and to public health authorities
for public health purposes.
HEALTH OVERSIGHT: We may disclose
PHI to a health oversight agency for activities authorized
by law, such as audits, investigations 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 rights laws.
ABUSE
OR NEGLECT: We may disclose your PHI to a public
health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your
PHI if we believe that you have been a victim of abuse, neglect
or domestic violence to the governmental entity or 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 PHI to a person or company required by the Food and
Drug Administration to report adverse events, product defects
or problems, biologic product deviations; to track products;
to enable product recalls; to make repairs or replacements;
or to conduct post marketing surveillance, as required.
CRIMINAL
ACTIVITY: Consistent with applicable federal and
state laws, we may disclose your PHI, if we believe 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 PHI if it is necessary for
law enforcement authorities to identify or apprehend an individual.
REQUIRED
BY LAW: We may use or disclose your PHI when we
are required to do so by law. For example, we must disclose
your PHI to the U.S. Department of Health and Human Services
upon request for purposes of determining whether we are in
compliance with federal privacy laws. We may disclose your
PHI when authorized by workers' compensation or similar laws.
PROCESS
AND PROCEEDINGS: We may disclose your PHI in response
to a court or administrative order, subpoena, discovery request
or other lawful process, under certain circumstances. Under
limited circumstances, such as court order, warrant or grand
jury subpoena, we may disclose your PHI to law enforcement
officials.
LAW ENFORCEMENT: We may disclose limited
information to a law enforcement official concerning the
PHI of a suspect, fugitive, material witness, crime victim
or missing person. We may disclose the PHI of an inmate or
other person in lawful custody to a law enforcement official
or correctional institution under certain circumstances.
We may disclose PHI where necessary to assist law enforcement
officials to capture an individual who as admitted to participation
in a crime or has escaped from lawful custody.
PATIENT RIGHTS
ACCESS: You have the right to look at or
get copies of your PHI, with limited exceptions. You must
make a request in writing to the contact person listed herein
to obtain access to your PHI. You may also request access
by sending us a letter to the address at the end of this
notice. If you request copies, we will charge you $0.25 for
each page of copied records and $5.00 for each X-ray copy.
If you prefer, we will prepare a summary or an explanation
of your PHI for a fee. Contact us using the information listed
at the end of this notice for a full explanation of our fee
structure.
ACCOUNTING OF DISCLOSURES: You have the
right to receive a list of instances in which we, or our
business associates, disclosed your PHI for purposes other
than treatment, payment, health care operations and certain
other activities after April 14, 2003. After April 14, 2009,
the accounting will be provided for the past six (6) years.
We will provide you with the date on which we made the disclosure,
the name of the person or entity to whom we disclosed your
PHI, a description of the PHI we disclosed, the reason for
the disclosure, and certain other information. If you request
this list more than once in a 12 month period, we may charge
you a reasonable, cost-based fee for responding to these
additional requests. Contact us using the information listed
at the end of this notice for a full explanation of our fee
structure.
RESTRICTION REQUESTS: You have the right
to request that we place additional restrictions on our use
and disclosure of your PHI. We are not required to agree
to these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency). Any agreement
we may make to a request for additional restriction must
be in writing signed by the person authorized to make such
an agreement on our behalf. We will not be bound unless our
agreement is so memorialized in writing. Please use the contact
information at the end of this form to obtain a Restriction
Request from.
CONFIDENTIAL COMMUNICATION: You have the
right to request that we communicate with you in confidence
about your PHI by alternative means or to an alternative
location. You must make you request in writing. We must accommodate
your request if it is reasonable, specifies the alternative
means or location, and continues to permit us to bill and
collect payment from you. Please use the contact information
at the end of this notice to obtain a Request for Confidential
Communications form.
AMENDMENT: You have the right to request
that we amend your PHI. Your request must be in writing and
it must explain why the information should be amended. We
may deny your request if we did not create the information
you want amended or for certain other reasons. If we deny
your request, we will provide you with a written explanation.
You may respond with a statement of disagreement to be appended
to the information you wanted amended. If we accept your
request to amend this information, we will make reasonable
efforts to inform others, including people or entities you
name, of the amendment and to include the changes in any
future disclosures of that information. Please use the contact
information at the end of this form to obtain a Request for
Amendment form.
ELECTRONIC NOTICE: If you receive this
notice on our website or by electronic mail (e-mail), you
are entitled to receive this information in written form.
Please contact us using the information listed at the end
of this notice to obtain this notice in written form.
QUESTIONS
AND COMPLAINTS
If you want more information about our privacy practices
or have questions or concerns, please contact us using the
information below.
If you believe that we may have violated
your privacy rights, or you disagree with a decision we made
about access to your PHI or in response to a request you
made, you may complain to us using the contact information
below. When possible, please use our Patient Complaint form,
which can be obtained using the contact information below.
You may also submit a written complaint to the U.S. Department
of Health and Human Services. If you wish to file a complaint
with them, we will provide with their address upon request.
We support your right to protect the privacy of your PHI.
We will not retaliate in any way if you choose to file a
complaint with us or with the U.S. Department of Health and
Human Services.
Name of Contact Person: Office Manager
Telephone: 312-337-9900 Fax:
312-337-9902
E-mail: staff@chicagopodiatry.com
Address: 467 West Erie
Chicago, IL 60654
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