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NOTICE OF PRIVACY PRACTICES - Effective Date - April 13, 2003
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.
If you have any questions about this notice, please contact the Privacy Officer.
OUR OBLIGATIONS
We are required by law to:
Maintain the privacy of protected health information (PHI)
Give you this notice of our legal duties and privacy practices regarding health information about you
Follow the terms of our notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
Described below are the ways we may use and disclose health information that identifies you
(protected health information or PHI). Except for the following purposes, we
will use and disclose PHI only with your written permission. You may revoke such
permission at any time by writing to our practice Privacy Officer.
TREATMENT.
We may use and disclose PHI for your treatment and to provide you with
treatment-related health care services. For example, we may disclose PHI to
doctors, nurses, technicians, or other personnel, including people outside our
office, who are involved in your medical care and need the information to
provide you with medical care.
PAYMENT.
We may use and disclose PHI so that
we or others may bill and receive payment from you, an insurance company, or a
third party for the treatment and services you received. For example, we may
give your health plan information so that they will pay for your
treatment.
HEALTH CARE OPERATIONS.
We may use and disclose PHI for health
care operation purposes. These uses and disclosures are necessary to make sure
that all of our patients receive quality care and to operate and manage our
office. For example, we may use and disclose information to make sure the
obstetrical or gynecological care you receive is of the highest quality. We also
may share information with other entities that have a relationship with you (for
example, your health plan) for their health care operation
activities.
APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES AND HEALTH RELATED BENEFITS AND SERVICES.
We may use and disclose PHI to contact you and to remind
you that you have an appointment with us. We also may use and disclose PHI to
tell you about treatment alternatives or health-related benefits and services
that may be of interest to you.
SPECIAL SITUATIONS
AS REQUIRED BY LAW.
We will disclose PHI when required to do so by international, federal, state or local law.
FAMILY AND FRIENDS.
We may disclose PHI to your family member or
close friend if we obtain your verbal agreement or if when given an opportunity
to object, you do not. We may also disclose PHI to family or friends if we can
infer from the circumstances, based on our professional judgment that you would
not object. For example, we may assume you agree to disclosure when you bring
your spouse with you into the exam room for discussion, evaluation, or
treatment.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY.
We may use and disclose PHI when necessary to prevent a serious threat to your health and
safety or the health and safety of the public or another person. Disclosures,
however, will be made only to someone who may be able to help prevent the threat.
EMERGENCY SITUATION.
We may use or disclose PHI to provide treatment in an emergency situation.
BUSINESS ASSOCIATES.
We may disclose PHI to our business associates that perform functions on our behalf or provide us with
services if the information is necessary for such functions or services. For
example, we may use another company to perform transcription services on our
behalf. All of our business associates are obligated to protect the privacy of
your information and are not allowed to use or disclose any information other
than as specified in our contract.
ORGAN AND TISSUE DONATION.
If you are an organ donor, we may use or release PHI to organizations that handle organ
procurement or other entities engaged in procurement; banking or transportation
of organs, eyes, or tissues to facilitate organ, eye or tissue donation; and
transplantation.
MILITARY AND VETERANS.
If you are a member of the armed forces, we may PHI as required by military command authorities. We also may
release PHI to the appropriate foreign military authority if you are a member of
a foreign military.
WORKERS' COMPENSATION.
We may release PHI for workersı compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
PUBLIC HEALTH RISKS.
We may disclose PHI for public health activities. These activities generally include disclosures to
prevent or control disease, injury or disability; report births and deaths;
report communicable or sexually transmitted diseases; report child abuse or
neglect; report reactions to medications or problems with products; notify
people of recalls of products they may be using; a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease or
condition; and the appropriate government authority if we believe a patient has
been the victim of abuse, neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized by law.
HEALTH OVERSIGHT ACTIVITIES.
We may disclose PHI to a health oversight agency for activities authorized by law.
These oversight activities include, for example,
investigations, audits, inspections, and licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
LAWSUITS AND DISPUTES.
If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a
court or administrative order. We also may disclose Health Information in
response to a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell you
about the request or to obtain an order protecting the informationrequested.
LAW ENFORCEMENT.
We may release PHI if asked by a law enforcement
official if the information is: (1) in response to a court order, subpoena,
warrant, summons or similar process; (2) limited information to identify or
locate a suspect, fugitive, material witness, or missing person; (3) about the
victim of a crime even if, under certain very limited circumstances, we are
unable to obtain the personıs agreement; (4) about a death we believe may be the
result of criminal conduct; (5) about criminal conduct on our premises; and (6)
in an emergency to report a crime, the location of the crime or victims, or the
identity, description or location of the person who committed the
crime.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS.
We may release PHI to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We also may release
PHI to funeral directors as necessary for their duties.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES.
We may release PHI to authorized federal officials for intelligence, counter-intelligence,
and other national security activities authorized by law. We may also disclose PHI to
authorized federal officials so they may provide protection to the President, other authorized persons, or
foreign heads of state, or to conduct special investigations.
INFORMATION NOT PERSONALLY IDENTIFIABLE.
We may use or disclose health information about you in a way that does not personally identify
you or reveal who you are.
Other Uses and Disclosures
We will not use or disclose your PHI for any purpose
other than those identified in the previous sections without your specific
Authorization. We must obtain your Authorization separate from any Consent we
may have obtained from you. If you give us Authorization to use or disclose PHI
about you, you may revoke that Authorization, in writing, at any time. If you
revoke your Authorization, we will no longer use or disclose information about
you for the reasons covered by your written Authorization, but we cannot take
back any uses or disclosures already made with your permission.
In Illinois, a specific written authorization (different than the Authorization and Consent
mentioned above) is required to disclose or release records of mental health
treatment, alcoholism treatment, drug abuse treatment or HIV/AIDS treatment
information.
We do not use or disclose PHI for marketing purposes or research activities.
YOUR RIGHTS
You have the following rights regarding PHI we have about you:
RIGHT TO INSPECT AND COPY.
You have a right to inspect and copy PHI that may be used to make decisions about your care or payment for your
care. This includes medical and billing records, other than psychotherapy notes.
To inspect and copy this PHI, you must make your request, in writing, to Privacy
Officer, Progressive Care for Women, S.C., 676 N. St. Clair Street, Suite 1800,
Chicago, IL 60611. If you request a copy of this information, we may charge a
fee as allowed under Illinois law. We may deny your request in certain limited
circumstances. You may ask that the denial be reviewed. If such a review is
required by law, we will select a licensed healthcare professional to review
your request and our denial. The person conducting the review will not be the
person who denied your request, and we will comply with the outcome review.
RIGHT TO AMEND.
If you feel that PHI we have is incorrect or incomplete, you
may ask us to amend the information. You have the right to request an amendment
for as long as the information is kept by or for our office. To request an
amendment, you must make your request, in writing, to Privacy Officer,
Progressive Care for Women, S.C., 676 N. St. Clair Street, Suite 1800, Chicago,
IL 60611. We may deny your request as permitted by law.
RIGHT TO AN ACCOUNTING OF DISCLOSURES.
You have the right to request a list of certain
disclosures we made of PHI for purposes other than treatment, payment and health
care operations or for which you provided written authorization. To request an
accounting of disclosures, you must make your request, in writing, to Privacy
Officer, Progressive Care for Women, S.C., 676 N. St. Clair Street, Suite 1800,
Chicago, IL 60611. We may charge you for the costs of providing the list. We
will notify you of the costs involved and you may choose to withdraw or modify
your request at that time before any costs are incurred.
RIGHT TO REQUEST RESTRICTIONS.
You have the right to request a restriction or limitation on the
PHI we use or disclose for treatment, payment, or health care operations. You
also have the right to request a limit on the PHI we disclose to someone
involved in your care or the payment for your care, like a family member or
friend. For example, you could ask that we not share information about a
particular diagnosis or treatment with your spouse. To request a restriction,
you must make your request, in writing, to Privacy Officer, Progressive Care for
Women, S.C., 676 N. St. Clair Street, Suite 1800, Chicago, IL 60611. We are not
required to agree to your request. If we agree, we will comply with your request
unless the information is needed to provide you with emergency
treatment.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION.
You have the right to request that we communicate with you about medical matters in a certain way or
at a certain location. For example, you can ask that we only contact you by mail
or at work. To request confidential communication, you must make your request,
in writing, to Privacy Officer, Progressive Care for Women, S.C., 676 N. St.
Clair Street, Suite 1800, Chicago, IL 60611. Your request must specify how or
where you wish to be contacted. We will accommodate reasonable
requests.
RIGHT TO A PAPER COPY OF THIS NOTICE.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any
time. Even if you have agreed to receive this notice electronically, you are
still entitled to a paper copy of this notice. You may obtain a copy of this
notice at our web site: www.pc4w.com To obtain a paper copy of this notice, ask
any of our office personal.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and make the new notice apply to PHI we already have
as well as any information we receive in the future. We will post a copy of our
current notice at our office. The notice will contain the effective date on the top of the page.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office
or with the Secretary of the Department of Health and Human Services. To file a
complaint with our office, contact Privacy Officer, Progressive Care for Women,
S.C., 676 N. St. Clair Street, Suite 1800, Chicago, IL 60611. All complaints
must be made in writing. You will not be penalized for filing a complaint.
YOU MUST ACKNOWLEDGE THIS PRIVACY POLICY. PLEASE FILL OUT THE INFORMATION BELOW.
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