NOTICE OF PRIVACY PRACTICES
for
ADVANCED PAIN CENTERS, S.C.
(referred to in this document as “the Practice”)
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.
This Notice of Privacy Practices is being provided to you as a requirement
of the Health Insurance Portability and Accountability Act (HIPAA). This
Notice describes how we may use and disclose your protected health information
to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your
rights to access and control your protected health information in some
cases. Your “protected health information” means any of your
written and oral health information, including demographic data that
can be used to identify you. This is health information that is created
or received by your health care provider, and that relates to your past,
present or future physical or mental health or condition.
I. Uses and Disclosures of Protected Health Information
The practice may use your protected health information for purposes
of providing treatment, obtaining payment for treatment, and conducting
health care operations. Your protected health information may be used
or disclosed only for these purposes unless the Practice has obtained
your authorization or the use or disclosure is otherwise permitted by
the HIPAA Privacy Regulations or State law. Disclosures of your protected
health information for the purposes described in this Notice may be made
in writing, orally, or by facsimile.
A. Treatment. We will use and disclose your protected health information
to provide, coordinate, or manage your health care and any related services.
This includes the coordination or management of your health care with
a third party for treatment purposes. For example, we may disclose your
protected health information to a pharmacy to fulfill a prescription,
to a laboratory to order a blood test, or to a home health agency that
is providing care in your home. We may also disclose protected health
information to other physicians who may be treating you or consulting
with your physician with respect to your care. In some cases, we may
also disclose your protected health information to an outside treatment
provider for purposes of the treatment activities of the other provider.
B. Payment. Your protected health information will be used, as needed,
to obtain payment for the services that we provide. This may include
certain communications to your health insurer to get approval for the
treatment that we recommend. For example, if a hospital admission is
recommended, we may need to disclose information to your health insurer
to get prior approval for the hospitalization.
We may also disclose protected health information to your insurance
company to determine whether you are eligible for benefits or whether
a particular service is covered under your health plan. In order to get
payment for your services, we may also need to disclose your protected
health information to your insurance company to demonstrate the medical
necessity of the services or, as required by your insurance company,
for utilization review. We may also disclose patient information to another
provider involved in your care for the other provider’s payment
activities.
We may also disclose information to our billing service and claim clearinghouse
to get payment for your services.
C. Operations. We may use or disclose your protected health information,
as necessary, for our own health care operations in order to facilitate
the function of the practice and to provide quality care to all patients.
Health care operations include such activities as:
• Quality assessment and improvement activities.
•
Employee review activities.
•
Training programs including those in which students, trainees, or practitioners
in health care learn under supervision.
•
Accreditation, certification, licensing or credentialing activities.
•
Review and auditing, including compliance reviews, medical reviews, legal
services and maintaining our compliance programs.
•
Business management and general administrative activities.
In certain situations, we may also disclose patient information to another
provider or health plan for their health care operations.
D. Other Uses and Disclosures. As part of treatment, payment and healthcare
operations, we may also use or disclose your protected health information
for the following purposes:
• To remind you of an appointment.
•
To inform you of potential treatment alternatives or options.
•
To inform you of health-related benefits or services that may be of
interest to you.
•
To contact you to raise funds for the practice or an institutional foundation
related to the practice.
If you do not wish to be contacted regarding fundraising, please contact
our Privacy Officer.
II. Uses and Disclosures Beyond Treatment, Payment and Health Care Operations
Permitted Without Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose your protected health
information without your permission or authorization for a number of
reasons including the following:
A. When Legally Required. We will disclose your protected health information
when we are required to do so by any Federal, State or local law.
B. When There Are Risks to Public Health. We may disclose your protected
health information for the following public activities and purposes:
·
To prevent, control, or report disease, injury or disability as permitted
by law.
·
To report vital events such as birth or death as permitted or required
by law.
·
To conduct public health surveillance, investigations and interventions
as permitted or required by law.
·
To collect or report adverse events and product defects, track FDA regulated
products, enable product recalls, repairs or replacements to the FDA
and to conduct post marketing surveillance.
·
To notify a person who has been exposed to a communicable disease or
who may be at risk of contracting or spreading a disease as authorized
by law.
·
To report to an employer information about an individual who is a member
of the workforce as legally permitted or required.
C. To Report Abuse, Neglect or Domestic Violence. We may notify government
authorities if we believe that a patient is the victim of abuse, neglect
or domestic violence. We will make this disclosure only when specifically
required or authorized by law or when the patient agrees to the disclosure.
D. To Conduct Health Oversight Activities. We may disclose your protected
health information to a health oversight agency for activities including
audits; civil, administrative or criminal investigations, proceedings,
or actions; inspections; licensure or disciplinary actions; or other
activities
necessary for appropriate oversight as authorized by law. We will not
disclose your protected health information if you are subject to an investigation
and your health information is not directly related to your receipt of
health care or public benefits.
E. In connection With Judicial and Administrative Proceedings. We may
disclose your protected health information in the course of any judicial
or administrative proceeding in response to an order of a court or
administrative tribunal as expressly authorized by such order or in
response to a signed authorization.
F. For Law Enforcement Purposes. We may disclose your protected health
information to a law enforcement official for law enforcement purposes
as follows:
• As required by law for reporting of certain types of wounds
or other physical injuries.
•
Pursuant to court order, court-ordered warrant, subpoena, summons or
similar process.
•
For the purpose of identifying or locating a suspect, fugitive, material
witness or missing person.
•
Under certain limited circumstances, when you are the victim of a crime.
•
To a law enforcement official if the practice has a suspicion that your
death was the result of criminal conduct.
•
In an emergency in order to report a crime.
G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose
protected health information to a coroner or medical examiner for identification
purposes, to determine cause of death or for the coroner or medical examiner
to perform other duties authorized by law. We may also disclose protected
health information to a funeral director, as authorized by law, in order
to permit the funeral director to carry out their duties. We may disclose
such information in reasonable anticipation of death. Protected health
information may be used and disclosed for cadaver organ, eye or tissue
donation purposes.
H. For Research Purposes. We may use or disclose your protected health
information for research when the use or disclosure for research has
been approved by an institutional review board or privacy board that
has reviewed the research proposal and research protocols to address
the privacy of your protected health information.
I. In the Event of A Serious Threat To Health Or Safety. We may, consistent
with applicable law and ethical standards of conduct, use or disclose
your protected health information if we believe, in good faith, that
such use or disclosure is necessary to prevent or lessen a serious and
imminent threat to your health or safety or to the health and safety
of the public.
J. For Specified Government Functions. In certain circumstances, the
Federal regulations authorize the practice to use or disclose your protected
health information 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.
K. For Worker’s Compensation. The practice may release your health
information to comply with worker’s compensation laws or similar
programs.
III. Uses and Disclosures Permitted Without Authorization But With Opportunity
to Object
We may disclose your protected health information to your family member
or a close personal friend if it is directly relevant to the person’s
involvement in your care or payment related to your care. We can also
disclose your information in connection with trying to locate or notify
family members or others involved in your care concerning your location,
condition or death.
You may object to these disclosures, If you do not object to these disclosures
or we can infer from the circumstances that you do not object or we determine,
in the exercise of our professional judgment, that it is in your best
interests for us to make disclosure of information that is directly relevant
to the person’s involvement with your care, we may disclose your
protected health information as described.
IV. Uses and Disclosures Which You Authorize
Other than as stated above, we will not disclose your health information
other than with your written authorization. You may revoke your authorization
in writing at any time except to the extent that we have taken action
in reliance upon the authorization.
V. Your Rights
You have the following rights regarding your health information:
A. The right to inspect and copy your protected health information.
You may inspect and obtain a copy of your protected health information
that is contained in a designated record set for as long as we maintain
the protected health information. A “designated record set” contains
medical and billing records and any other records that your physician
and the practice use for making decisions about you.
Under Federal law, however, you may not inspect or copy the following
records:
psychotherapy notes; information compiled in reasonable anticipation
of, or for use in, a civil, criminal, or administrative action or proceeding;
and protected health information that is subject to a law that prohibits
access to protected health information. Depending on the circumstances,
you may have the right to have a decision to deny access reviewed.
We may deny your request to inspect or copy your protected health information
if, in our professional judgment, we determine that the access requested
is likely to endanger your life or safety or that of another person,
or that it is likely to cause substantial harm to another person referenced
within the information. You have the right to request a review of this
decision.
To inspect and copy your medical information, you must submit a written
request to the Privacy Officer whose contact information is listed on
the last pages of this Notice. If you request a copy of your information,
we may charge you a fee for the costs of copying, mailing or other costs
incurred by us in complying with your request.
Please contact our Privacy Officer if you have questions about access
to your medical record.
B. The right to request a restriction on uses and disclosures of your
protected health information. You may ask us not to use or disclose certain
parts of your protected health information for the purposes of treatment,
payment or health care operations. You may also request that we not disclose
your health information to family members or friends who may be involved
in your care or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
The practice is not required to agree to a restriction that you may
request. We will notify you if we deny your request to a restriction,
If the practice does agree to the requested restriction, we may not use
or disclose your protected health information in violation of that restriction
unless it is needed to provide emergency treatment. Under certain circumstances,
we may terminate our agreement to a restriction. You may request a restriction
by contacting the Privacy Officer.
C. The right to request to receive confidential communications from
us by alternative means or at an alternative location. You have the right
to request that we communicate with you in certain ways. We will accommodate
reasonable requests. We may 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 require
you to provide an explanation for your request. Requests must be made
in writing to our Privacy Officer.
D. The right to have your physician amend your protected health information.
You may request an amendment of protected health information about you
in a designated record set for as long as we maintain this information.
In certain cases, we may deny your request for an amendment. TI we deny
your request for 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. Requests for amendment
must be in writing and must be directed to our Privacy Officer. In this
written request, you must also provide a reason to support the requested
amendments.
E. The right to receive an accounting. You have the right to request
an accounting of certain disclosures of your protected health information
made by the practice. This right applies to disclosures for purposes
other than treatment, payment or health care operations as described
in this Notice of Privacy Practices. We are also not required to account
for disclosures that you requested, disclosures that you agreed to by
signing an authorization form, disclosures for a facility directory,
to friends or family members involved in your care, or certain other
disclosures we are permitted to make without your authorization. The
request for an accounting must be made in writing to our Privacy Officer.
The request should specify the time period sought for the accounting.
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. Subsequent accounting
requests may be subject to a reasonable cost-based fee.
F. The 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 the notice or have agreed to accept this notice electronically.
VI. Our Duties
The practice is required by law to maintain the privacy of your health
information and to provide you with this Notice of our duties and privacy
practices. We are required to abide by terms of this Notice as may be
amended from time to time. We reserve the right to change the terms of
this Notice and to make the new Notice provisions effective for all protected
health information that we maintain, If the practice changes its Notice,
we will provide a copy of the revised Notice by sending a copy of the
Revised Notice via regular mail or through in-person contact.
VII. Complaints
You have the right to express complaints to the practice and to the
Secretary of Health and Human Services if you believe that your privacy
rights have been violated. You may complain to the practice by contacting
the practice’s Privacy Officer verbally or in writing, using the
contact information below. We encourage you to express any concerns you
may have regarding the privacy of your information. You will not be retaliated
against in any way for filing a complaint.
VIII. Contact Person
The practice’s contact person for all issues regarding patient
privacy and you rights under the Federal privacy standards is the Privacy
Officer. Information regarding matters covered by this Notice can be
requested by contacting the Privacy Officer. Complaints against the practice
can be mailed to the Privacy Officer by sending it to:
ATTN: Privacy Officer
ADVANCED PAIN CENTERS, S.C.
2260 W Higgins Road
Suite 101
Hoffman Estates, IL 60169
The Privacy Officer can be contacted by telephone at — (847) 608-6620.
IX. Effective Date
This Notice is effective April 14, 2003.
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