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.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:
Privacy Officer: Christina Peugh
Address: 4909 N. Glen Park Place, Peoria, IL 61614
Telephone: 309-674-7546 Fax: 309-282-2075
We obtain health information, or “Protected Health Information” or “PHI”, in order to treat you, receive payment for services, and to comply with certain policies and laws. We are required by law to maintain the privacy of PHI, to give you this Notice of Privacy Practices (“Notice”) explaining our privacy practices with regard to that information, and to ask you to sign an acknowledgment that you received this Notice. This Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.
How We May Use and Disclose Your PHI
We may use your PHI for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your PHI may be used or disclosed only for these purposes unless we have obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your PHI for the purposes described in this Notice may be made in writing, orally, electronically, or by facsimile. In addition, the physicians and/or nurse anesthetists of Associated Anesthesiologists, S.C., working in association with the Peoria Ambulatory Surgery Center, may also use your PHI for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. We may use and disclose your PHI in the following circumstances:
- Treatment. We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services, including the coordination or management of your health care with a third party for treatment purposes. For example, your PHI may be provided to a physician or other health care provider (e.g., a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose you, treat you, or provide you with a service.
- Payment. We may use and disclose your PHI to bill and collect payment for the treatment and services you receive from us. This may include activities that your health insurance plan may undertake before it approves or pays for the health care services, such as making an eligibility or coverage determination for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, your health plan may need your PHI before it will agree to pay for treatment.
- Health Care Operations. We may use and disclose your PHI for our own health care operations to facilitate the function of SDC and to provide quality care to all patients. Health care operations include activities like quality assessment and improvement activities, employee review activities, training, and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities. For example, we may use your PHI to internally review the quality of the care you receive and to evaluate our team members’ performance. We may also disclose information to other physicians, health care providers, medical students, and other authorized personnel for educational purposes. In certain situations, we may also disclose PHI to another provider or health plan for their health care operations.
- Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
- Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
- Research. We may use and disclose your PHI for research purposes, but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your PHI. Even without that approval, we may permit researchers to look at PHI to help them prepare for research, for example, to allow them to identify patients who may be included in their research project, as long as they do not remove or take a copy of any PHI. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research. However, we will only disclose the limited data set if we enter into a data use agreement with the recipient who must agree to (1) use the data set only for the purposes for which it was provided, (2) ensure the confidentiality and security of the data, and (3) not identify the information or use it to contact any individual.
- As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law.
- Public Health or Safety. We may use and disclose PHI when necessary to prevent a serious and imminent threat to your health or safety or to the health or safety of others. We may also disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your PHI.
- Organ and Tissue Donation. If you are an organ or tissue donor, we may use or disclose your PHI to organizations that handle organ procurement or transplantation – such as an organ donation bank – as necessary to facilitate organ or tissue donation and transplantation.
- Specified Government Functions. We may use or disclose your PHI to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
- Workers’ Compensation. We may use or disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
- Abuse, Neglect, or Domestic Violence. We may disclose PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.
- Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.
- 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 PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit.
- Law Enforcement. We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.
- Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties.
Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out
- Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend 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.
- Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
- Fundraising Activities. We may use or disclose your PHI, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications. If you do not want to receive these materials, please submit a written request to the Privacy Officer.
Uses and Disclosures which You Authorize
The following uses and disclosures of your PHI will be made only with your written authorization: (1) uses and disclosures of PHI for marketing purposes; and (2) disclosures that constitute a sale of your PHI. Other than as stated in this Notice or the laws that apply to us, we will not disclose your health information other than with your written authorization. You may revoke your authorization at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. Any disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
Your Rights Regarding Your PHI
You have the following rights, subject to certain limitations, regarding your PHI:
- Right to look at and copy of your PHI. You have the right to look at and copy PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
- Right to a Summary or Explanation. We can also provide you with a summary of your PHI, rather than the entire record, or we can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees.
- Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.
- Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
- Right to Request Restrictions on Uses and Disclosures of your PHI. You may ask us not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request a restriction, you must submit a written request to our Privacy Officer. You must state the specific restriction requested and to whom you want the restrictions apply. Revocation will not apply to information that has already been released. We are not required to agree to a restriction that you may request unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. We will notify you if we deny your request to a restriction. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction.
- Out-of-Pocket Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
- Right to Request Confidential Communications of your PHI. You have the right to request that we communicate with you in certain ways. For example, you may request that we contact you by mail at a specific address or call you only at your work number. We will not ask you the reason for your request. Requests must be made in writing to our Privacy Officer and you must specify how or where we are to contact you. We will accommodate reasonable requests.
- Right to Request Amendments to your PHI. If you feel that the 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 us. A request for amendment must be made in writing to the Privacy Officer and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
- Right to Receive an Accounting. You have the right to request an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures we have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge, but subsequent accounting requests may be subject to a reasonable cost-based fee.
- Right to Obtain a Paper Copy of this Notice. Upon request, we will provide a separate paper copy of this Notice even if you have already received a copy of this Notice or have agreed to accept this Notice electronically.
Changes to this Notice – We reserve the right to change the terms of this Notice. We reserve the right to make the new Notice provisions effective for all PHI that we already have as well as for any Protective Health Information we create or receive in the future. If we change/revise our Notice, we will provide a copy of the revised Notice at your next visit. A copy of our current Notice in posted in our office lobby and on our website.
How to Exercise Your Rights
To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your PHI, you may also contact your physician directly. To obtain a paper copy of this Notice, contact our Privacy Officer by phone, email, or mail.
You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated: All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint. To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.