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.
Uses and Disclosures: We use health information about you
for treatment, to obtain payment for treatment, for administrative
purposes, and to evaluate the quality of care that you receive.
Continuity of care is part of treatment and your records may
be shared with other providers to whom you are referred. We
may use or disclose Protected Health Information about you
without your authorization in several situations, but beyond
those situations, we will ask for your written authorization
before using or disclosing any Protected Health Information
Uses and Disclosures of Protected Health Information Following
are examples of the types of uses and disclosures of your
Protected Health Information that the provider is permitted
These examples are not meant to be exhaustive, but to describe
the types of uses and disclosures.
We will use and disclose your Protected Health Information
to provide, coordinate, or manage your health care and any
related services. For example, your Protected Health Information
may be provided to a doctor to whom you have been referred
to ensure that the doctor has the necessary information
to diagnose or treat you.
Payment: Your Protected Health Information will be used,
as needed, in activities related to obtaining payment for
your health care services. For example, obtaining approval
for a hospital stay may require that your relevant Protected
Health Information be disclosed to your health insurance
company or governmental plan to obtain approval for the
Operations: We may use or disclose, as-needed, your Protected
Health Information in order to support our business activities.
For example, when we review employee performance, we may
need to look at what an employee has documented in your
Associates: We may share your Protected Health Information
with a third party ‘Business Associate’ that
performs various activities (e.g., billing, transcription
services). Whenever an arrangement between us and a Business
Associate involves the use or disclosure of your Protected
Health Information, we will have a written contract that
contains terms that will protect the privacy of your Protected
We may use or disclose certain health information in the
course of providing you with information about treatment
alternatives, health-related services, or fund-raising.
You may contact us to request that these materials not be
sent to you.
reminders: We may contact you to provide appointment reminders.
Involved in Your Care or Payment for your care: We may release
medical information to a friend or family member who is
involved in your medical care. We may also give information
to someone who helps pay for your care. We may also tell
your family and/or friends your condition, and that you
are under our care. In addition we may disclose medical
information to an entity assisting in a disaster relief
effort so that your family can be notified about your condition,
status and location.
Health: for public health purposes to a public health authority
or to a person who is at risk of contracting or spreading
Oversight: to a health oversight agency for activities authorized
by law, such as audits, investigations, and inspections.
or Neglect: to an appropriate authority to report child
abuse or neglect, if we believe that you have been a victim
of abuse, neglect, or domestic violence.
and Drug Administration: as required by the Food and Drug
Administration to track products.
Proceedings: in the course of legal proceedings.
Enforcement: for law enforcement purposes, such as pertaining
to victims of a crime or to prevent a crime.
Funeral Directors, and Organ Donation: for the coroner,
medical examiner, or funeral director to perform duties
authorized by law and for organ donation purposes.
to researchers, when their research has been approved by
an Institutional Review Board or Privacy Board, or the Protected
Health Information has been de-identified.
Inmates, and National Security: to military supervisors
of Armed Forces personnel or to custodians of inmates, as
necessary. Preserving national security may also necessitate
disclosure of Protected Health Information.
Compensation and Auto Insurance Company: to comply with
workers’ compensation laws.
to the Department of Health and Human Services to investigate
In general, we may use or disclose your Protected Health Information
as required by law and limited to the relevant requirements
of the law.
use and disclose your Protected Health Information in the
following instances. You have the opportunity to object. If
you are not present or able to object, then your provider
may, using professional judgment, determine whether the disclosure
is in your best interest.
Directories: Unless you object, we will use and disclose
in our facility directory your name, the location at which
you are receiving care, your condition (in general terms),
and your religious affiliation. All of this information,
except religious affiliation, will be disclosed to people
that ask for you by name. Members of the clergy will be
told your religious affiliation.
Involved in Your Healthcare: Unless you object, we may disclose
to a member of your family, a relative, a close friend or
any other person you identify, your Protected Health Information
that directly relates to that person’s involvement
in your health care.
In an emergency treatment situation, we will provide you
a Notice of Privacy Practices as soon as reasonably practicable
after the delivery of treatment.
Barriers: We may use and disclose your Protected Health
Information if we have attempted to obtain Acknowledgement
from you of our Notice of Privacy Practices but have been
unable to do so due to substantial communication barriers
and we determine, using professional judgment, that you
uses and disclosures of your Protected Health Information
will be made only with your written authorization, unless
otherwise permitted or required by law as described below.
You may revoke your authorization, at any time, in writing.
of when an authorization is required are as follows:
disclose Protected Health Information about a patient to
a third party (i.e., a life insurance underwriter).
market a product or service except if the marketing communication
is face-to-face with the patient or it involves the provision
of services of nominal value.
raise funds for any entity other than our practice.
research: Unless the research has been approved by an Institutional
Review Board or Privacy Board, or the Protected Health Information
has been de-identified.
use Psychotherapy notes, unless Use or Disclosure is required
- Law enforcement purposes or legal mandates.
- Oversight of the provider who created the notes.
- A coroner or medical examiner.
- Avoidance of a serious and imminent threat to health or
Your rights: In most cases, you have the right
to look at or get a copy of health information about you.
If you request copies, we will charge you only normal photocopy
fees. You also have the right to receive a list of certain
types of disclosures of your information that we made. If
you believe that information in your record is incorrect,
you have the right to request that we correct the existing
the right to:
and Copy your Protected Health Information. However, we
may refuse to provide access to certain psychotherapy notes
or information for a civil or criminal proceeding.
a Restriction of your Protected Health Information. You
may ask us not to use or disclose certain parts of your
Protected Health Information for treatment, payment or healthcare
operations. You may also request that information not be
disclosed to family members or friends who may be involved
in your care. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may
request, but if we do agree, then we must act accordingly.
to receive confidential communications from us by alternative
means or at an alternative location. We will accommodate
reasonable requests. We may also condition this accommodation
by asking you for information as to how payment will be
handled or specification of an alternative address or other
method of contact. We will not request an explanation from
you as to the basis for the request.
us to Amend your Protected Health Information. You may request
an amendment of Protected Health Information about you.
If we deny your request for amendment, you have the right
to file a Statement of Disagreement with us, and your medical
record will note the disputed information.
an Accounting of certain disclosures we may have made. This
right applies to Disclosures for purposes other than treatment,
payment or healthcare operations. It excludes Disclosures
we may have made to you, for a facility directory, to family
members or friends involved in your care, or for notification
purposes. It also excludes Disclosures made pursuant to
an Authorization from you, or for Incidental Disclosures
or Disclosures made for certain purposes such as national
security, or to a correctional facility. You have the right
to receive specific information regarding Disclosures not
excluded above. The right to receive this information is
subject to certain exceptions, restrictions and limitations.
The first time you request such a list, there will be no
charge to you. Subsequent lists requested in the same year
will be charged a nominal fee.
Our legal duty: We are required by law to protect the
privacy of your information, provide this notice about our
information practices, follow the information practices that
are described in this notice, and seek your acknowledgement
of receipt of this notice. Before we make a significant change
in our policies, we will change our notice and post the new
notice in the waiting area. You can also request a copy of
our notice at any time. For more information about our privacy
practices, contact the person listed below.
If you are concerned that we have violated your privacy rights,
or you disagree with a decision we made about access to your
records, you may contact the person listed below. You also
may send a written complaint to the U.S. Department of Health
and Human Services. The person listed below can provide you
with the appropriate address upon request.
If you have any questions or complaints, please contact:
Center for Pain Management
1012 W. 95th Street,
Naperville IL 60564