PROVIDER 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 about you.

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 to make.
These examples are not meant to be exhaustive, but to describe the types of uses and disclosures.

• Treatment: 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 hospital admission.
• Healthcare 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 medical record.
• Business 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 Health Information.
• Marketing: 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.
• Appointment reminders: We may contact you to provide appointment reminders.
• Individuals 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.
• Public Health: for public health purposes to a public health authority or to a person who is at risk of contracting or spreading your disease.
• Health Oversight: to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
• Abuse 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.
• Food and Drug Administration: as required by the Food and Drug Administration to track products.
• Legal Proceedings: in the course of legal proceedings.
• Law Enforcement: for law enforcement purposes, such as pertaining to victims of a crime or to prevent a crime.
• Coroners, Funeral Directors, and Organ Donation: for the coroner, medical examiner, or funeral director to perform duties authorized by law and for organ donation purposes.
• Research: 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.
• Soldiers, 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.
• Workers’ Compensation and Auto Insurance Company: to comply with workers’ compensation laws.
• Compliance: to the Department of Health and Human Services to investigate our compliance.

In general, we may use or disclose your Protected Health Information as required by law and limited to the relevant requirements of the law.

Opportunity to Object

We may 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.

• Facility 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.
• Others 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.
• Emergencies: In an emergency treatment situation, we will provide you a Notice of Privacy Practices as soon as reasonably practicable after the delivery of treatment.
• Communication 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 would agree.

Written Authorization

Other 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.

Some examples of when an authorization is required are as follows:

• To disclose Protected Health Information about a patient to a third party (i.e., a life insurance underwriter).
• To 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.
• To raise funds for any entity other than our practice.
• For research: Unless the research has been approved by an Institutional Review Board or Privacy Board, or the Protected Health Information has been de-identified.
• To use Psychotherapy notes, unless Use or Disclosure is required for:
  - 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 safety.

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 information.

You have the right to:

• Inspect 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.
• Request 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.
• Request 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.
• 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.
• Receive 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.

Complaints: 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:

Dr.Firdaus Hashim
Privacy Officer
Center for Pain Management
1012 W. 95th Street,
Naperville IL 60564
PH 630-778-4774