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Notice
of Privacy Practices |
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UNDERSTANDING
YOUR HEALTH INFORMATION AND MEDICAL RECORD
EACH TIME YOU VISIT A HOSPITAL, PHYSICAN, OR
OTHER HEALTH CARE PROVIDER, THEY DOCUMENT INFORMATION ABOUT
YOU AND YOUR VISIT. TYPICALLY, THIS RECORD IS REFERRED TO AS
YOUR MEDICAL RECORD AND CONTAINS YOUR NAME, SYMPTOMS, HEALTH
HISTORY AND EXAM, TEST RESULTS, DIAGNOSIS, TREATMENT GIVEN AND
A PLAN FOR FUTURE CARE OR TREATMENT. THIS MEDICAL RECORD IS
USED TO PLAN YOUR CARE AND TREATMENT AND BE A SOURCE OF YOUR
HEALTH INFORMATION AS DESCRIBED BELOW.
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YOUR
HEALTH INFORMATION RIGHTS
YOUR MEDICAL RECORD IS THE PHYSICAL PROPERTY
OF SOUTHWEST PEDIATRICS, LTD, HOWEVER THE INFORMATION WITHIN
YOUR MEDICAL RECORD BELONGS TO YOU. FEDERAL AND ILLINOIS LAWS
PROVIDES YOU WITH THE FOLLOWING RIGHTS REGARDING YOUR HEALTH
INFORMATION THAT IS CONTAINED IN THE MEDICAL RECORD THAT SOUTHWEST
PEDIATRICS, LTD KEEPS ABOUT YOU.
- RIGHT TO OBTAIN THIS COPY OF THIS NOTICE
OF PRIVACY PRACTICES.
- RIGHT TO REQUEST CERTAIN RESTRICTIONS
ON THE USES AND DISCLOSURES OF YOUR HEALTH INFORMATION.
- RIGHT TO INSPECT OR RECEIVE A COPY OF
YOUR HEALTH RECORD.
- RIGHT TO REQUEST AN AMENDMENT TO YOUR
HEALTH RECORD IF YOU BELIEVE IT CONTAINS AN ERROR.
- RIGHT TO OBTAIN AN ACCOUNTING OF DISCLOSURES
OF YOUR HEALTH INFORMATION.
- RIGHT TO REQUEST THAT WE COMMUNICATE
WITH YOU ABOUT YOUR HEALTH CARE AT A CONFINDENTIAL PHONE
NUMBER OR ADDRESS.
- RIGHT TO REVOKE YOUR WRITTEN CONSENT
/ AUTHORIZATION TO USE OR DISCLOSE YOUR HEALTH INFORMATION
EXCEPT WHEN THE USE OR DISCLOSURE HAS ALREADY HAPPENED.
FEDERAL AND ILLINOIS
LAWS ALSO PROVIDE YOU WITH THE RIGHT TO BE INFORMED OF AND
GIVE YOUR WRITTEN AUTHORIZATION BEFORE ANY HEALTH INFORMATION
INCLUDING HIGHLY CONFIDENTIAL INFORMATION, IS DISCLOSED, UNLESS
SUCH DISCLOSURE IS ALLOWED OR REQUIRED BY LAW. EXAMPLES OF
HIGHLY CONFIDENTIAL INFORMATION ARE MENTAL HEALTH TREATMENT
INFORMATION, INCLUDING PSYCHOTHERAPY NOTES, SUBSTANCE ABUSE
PREVENTION, TREATMENT OR REFERRAL, DEVELOPMENTAL DISABILITY
SERVICES, HIV/AIDS TESTING AND TREATMENT, VENERAL DISEASES
TREATMENT, GENETIC TESTING, SEXUAL ASSAULT TREATMENT, OR THE
ABUSE OR NEGLECT OF A CHILD OR DISABLED ADULT.
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SOUTHWEST
PEDIATRICS, LTD’S RESPONSIBILITIES
- MAINTAIN THE PRIVACY
OF YOUR HEALTH INFORMATION AS REQUIRED BY LAW.
- PROVIDE YOU WITH
A NOTICE AS TO OUR LEGAL DUTIES AND PRIVACY PRACTICES WITH
RESPECT TO INFORMATION WE COLLECT AND MAINTAIN ABOUT YOU
- DO WHAT IS REQUIRED
BY THIS NOTICE OR THAT NOTICE THAT IS IN EFFECT AT THE TIME
SOUTHWEST PEDIATRICS, LTD USES OR DISCLOSES YOUR HEALTH
INFORMATION.
- NOTIFY YOU IF WE
ARE UNABLE TO AGREE TO YOUR REQUESTED RESTRICTION ON OUR
DISCLOSURE OF YOUR HEALTH INFORMATION.
- AGREE TO REASONABLE
REQUESTS YOU MAY HAVE TO COMMUNICATE YOUR HEALTH INFORMATION
BY AN ALTERNATIVE WAY OR AT AN ALTERNATIVE PLACE.
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WE RESERVE THE RIGHT TO CHANGE
OUR PRIVACY PRACTICES AND TO USE A NEW NOTICE OF PRIVACY PRACTICES
FOR ALL HEALTH INFORMATION WE MAINTAIN ABOUT YOU OR OTHER PATIENTS.
IF SOUTHWEST PEDIATRICS, LTD CHANGES ITS PRACTICE; A NEW NOTICE
OF PRIVACY PRACTICE FORM WILL BE AVAILABLE UPON YOUR REQUEST,
BY MAIL OR IN PERSON AT THIS FACILITY.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
SOUTHWEST PEDIATRICS, LTD WILL USE AND DISCLOSE YOUR HEALTH
INFORMATION CONTAINED WITHIN THE SOUTHWEST PEDIATRICS, LTD
MEDICAL RECORD TO GIVE YOU TREATMENT, OBTAIN PAYMENT FOR YOUR
TREATMENT AND OPERATE OUR HEALTHCARE BUSINESSES.
WE
WILL USE YOUR HEALTH INFORMATION FOR TREATMENT
FOR EXAMPLE: YOUR HEALTHCARE TEAM WILL COLLECT AND DOCUMENT
INFORMATION ABOUT YOU IN YOUR HEALTH RECORD. THEY WILL USE
THIS INFORMATION TO CHOOSE THE TREATMENT THEY BELIEVE IS BEST
FOR YOU.
WE
WILL USE YOUR HEALTH INFORMATION FOR PAYMENT
FOR EXAMPLE: WE WILL SEND YOU A BILL THAT INCLUDES SOME OF
YOUR HEALTH INFORMATION OR A COPY OF PART OR ALL OF YOUR HEALTH
RECORD TO YOUR THIRD PARTY PAYER SUCH AS YOUR HEALTH INSURANCE
COMPANY. THE TYPE OF HEALTH INFORAMTION WE WILL SEND INCLUDES
YOUR NAME AND OTHER IDENTIFYING INFORMATION, DIAGNOSIS, TREATMENT
AND THE PROCEDURES AND SUPPLIES PROVIDED DURING YOUR TREATMENT.
WE
WILL USE YOUR HEALTH INFORMATION FOR OUR ROUTINE OPERATIONS
FOR EXAMPLE: YOUR HEALTHCARE TEAM WILL USE YOUR HEALTH INFORMATION
TO REVIEW YOUR TREATMENT AND ITS OUTCOMES. THEY MAY ALSO COMPARE
YOUR TREATMENT TO OTHERS TO CONTINUALLY IMPROVE THE QUALITY
AND EFFECTIVENESS OF OUR SERVICES.
OTHER USES OF YOUR HEALTH INFORMATION
WE
RECEIVE YOUR WRITTEN AUTHORIZATION TO USE AND/OR DISCLOSE
YOUR HEALTH INFORMATION.
WE WILL USE AND/OR DISCLOSE YOUR HEALTH INFORMATION TO THOSE
PERSONS OR PLACES FOR WHICH YOU GIVE US YOUR WRITTEN AUTHORIZATION
OR PERMISSION TO DO SO. IF YOU AUTHORIZE US TO USE OR DISCLOSE
YOUR INFORMATION, YOU MUST COMPLETE OUR RELEASE OF HEALTH
INFORMATION FORM. YOU MAY REVOKE YOUR AUTHORIZATION IN
WRITING AT ANY TIME EXCEPT TO THE EXTENT THAT WE HAVE ALREADY
USED OR DISCLOSED YOUR HEALTH INFORMATION AS YOU AUTHORIZED.IF
YOUR HEALTH INFORMATION INCLUDES HIGHLY CONFIDENTIAL INFORMATION,
WE MAY ONLY USE AND DISCLOSE SUCH INFORMATION FOR TREATMENT,
PAYMENT AND OPERATIONS AS DESCRIBED ABOVE, OTHERWISE, YOU
MUST GIVE US YOUR WRITTEN AUTHORIZATION TO DISCLOSE YOUR HIGHLY
CONFIDENTIAL INFORMATION. A PERSON WHO CAN VERIFY YOUR IDENTITY
MUST WITNESS AND CO-SIGN AN AUTHORIZATION TO RELEASE HEALTH
INFORMATION FORM ABOUT TREATMENT FOR A MENTAL ILLNESS OR DEVELOPMENTAL
DISABILITY.
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FOR THE PURPOSED DESCRIBED BELOW.
BUSINESS ASSOCIATES: WE PROVIDE SOME
SERVICES THAT REQUIRE USING OR DISCLOSING YOUR HEALTH INFORMATION
TO OTHER CONTRACTORS WHO ARE PERSONS OR COMPANIES THAT PERFORM
THE ACTUAL SERVICE. THE LAW REFERS TO THESE CONTRACTORS AS
OUR BUSINESS ASSOCIATES. EXAMPLES OF THESE BUSINESS ASSOCIATES
ARE BILLING AND COMPUTER SERVICES. WE MAY DISLCOSE YOUR HEALTH
INFORMATION TO THEM SO THAT THEY CAN DO THE JOB WE HAVE CONTRACTED
THEM TO DO. WE REQUIRE THAT THEY USE APPROPIATE SAFEGUARDS
TO ENSURE THE PRIVACY OF YOUR HEALTH INFORMATION.
HEALTH OVERSIGHT ACTIVITIES AND SPECIALIZED GOVERNMENT
FUNCTIONS:
WE MAY DISCLOSE YOUR HEALTH INFORMATION TO AN AGENCY THAT
OVERSEES THE HEALTHCARE SYSTEM AND ENSURES COMPLIANCE WITH
THE RULES OF GOVERNMENT HEALTH PROGRAMS SUCH AS MEDICARE AND
MEDICAID, TO THE U.S. MILITARY OR U.S. DEPARTMENT OF STATE
UNDER CERTAIN CIRCUMSTANCES.
LAW ENFORCEMENT OFFICIALS AND COURT OR
ADMINISTRATIVE ORDERS:
WE MAY DISCLOSE YOUR HEALTH INFORMATION TO THE POLICE, OTHER
LAW ENFORCEMENT OFFICIALS, MEDICAL EXAMINERS OR CORONERS,
AND TO THE COURTS OR ADMINISTRATIVE PROCEEDINGS AS ALLOWED
OR REQUIRED BY LAW, OR REQUIRED BY A COURT ORDER OR OTHER
LEGAL PROCESS.
PUBLIC HEALTH ACTIVITIES
WE MAY REPORT YOUR IDENTITY AND OTHER HEALTH INFORMATION TO:
PUBLIC HEALTH AUTHORITIES FOR THE PURPOSE OF CONTROLLING DISEASE,
INJURY OR DISABILITY, TO THE U.S. FOOD AND DRUG ADMINISTRATION
FOR REGULATING CERTAIN PRODUCTS OR ACTIVITIES, TO GOVERMENTAL
AUTHORITIES ABOUT SUSPECTED OR KNOWN CHILD ABUSE AND NEGLECT,
ADULT ABUSE AND NEGLECT, OR DOMESTIC VIOLENCE, TO A PERSON
EXPOSED TO A CONTAGIOUS DISEASE OR HAS THE RISK OF CONTRACTING
OR SPREADING A DISEASE, TO YOUR EMPLOYER AND GOVERMENTAL AGENCIES
AS REQUIRED BY FEDERAL AND STATE LAWS, WORK RELATED ILLNESS
OR INJURY, TO PREVENT OR LESSEN A SERIOUS OR IMMINENT THREAT
TO A PERSON’S OR THE PUBLIC’S HEALTH OR SAFETY,
OR TO A PUBLIC OR PRIVATE ENTITY THAT IS AUTHORIZED TO ASSIST
IN DISASTER RELIEF EFFORTS.
OTHER COMMUNICATIONS WITH YOU
WE MAY CONTACT YOU IN REGARDS TO YOUR CHILD’S APPOINTMENTS
WITH YOUR HEALTH CARE TEAM AND TO FOLLOW UP ON THEM. UNLESS
YOU NOTIFY US THAT YOU OBJECT, WE MAY ALSO CONTACT YOU ABOUT
OTHER HEALTH CARE SERVICES WE OFFER THAT MAY BENEFIT YOU.
RIGHT TO FILE A COMPLAINT
IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU
MAY FILE A COMPLAINT WITH SOUTHWEST PEDIATRICS, LTD, OR THE
DIRECTOR OF THE OFFICE OF CIVIL RIGHTS, U.S. SECRETARY OF
HEALTH AND HUMAN SERVICES. WE WILL NOT RETALIATE AGAINST YOU
IF YOU FILE A COMPLAINT WITH US OR WITH THE DIRECTOR. IF YOU
WOULD LIKE TO REPORT A PRIVACY PROBLEM OR WANT FURTHER INFORMATION,
PLEASE CONTACT OUR PRIVACY OFFICER, JENNIFER HANNA AT 708-361-3300
X 226.
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