NOTICE OF PRIVACY PRACTICES
Revised: May 20, 2016
OUR LEGAL OBLIGATIONS
Maintain the privacy of your protected health information (PHI). Provide you notice of our legal duties and privacy practices regarding your PHI. Follow the terms of our notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
Described below are ways we may use and disclose PHI. Except as provided in this Notice, we will use and disclose PHI only with your written authorization. You may revoke such authorization at any time by writing to our practice Privacy Officer.
TREATMENT: We may use and disclose PHI for your treatment and to provide you with treatmentrelated health care services. This means that your PHI may be disclosed to doctors, nurses, technicians or other personnel, both inside and outside of our office, who are involved in your care. Additionally we may use and disclose PHI to inform you about treatment alternatives or healthrelated benefits and services that may be of interest to you.
PAYMENT: We may use and disclose PHI so that we, or others may bill and receive payment from you, such as a third party for the treatment and services you received.
HEALTH CARE OPERATIONS: We may use and disclose PHI for health care operation purposes. These uses and disclosures are necessary to make sure that our clients receive quality care and to operate and manage our office. For example, we may use and disclose PHI to make sure the treatments and other services you receive are of the highest quality.
APPOINTMENT REMINDERS: We may use and disclose PHI to contact you and to remind you that you have an appointment with us.
SPECIAL SITUATIONS AS REQUIRED BY LAW: We will disclose PHI as required to do so by international, federal, state or local laws.
FAMILY & FRIENDS: We may disclose PHI to family members or close friends if we receive your written agreement or if when given an opportunity to object, you do not. We may also disclose PHI to family and friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to disclosure when you bring your spouse, family member or friend into the treatment room for discussion, evaluation or treatment.
EMERGENCY SITUATIONS OR TO AVERT A SERIOUS THREAT TO HEALTH AND SAFETY: We may use and disclose PHI in an emergency situation or to prevent a serious threat to your health or safety or the health and safety of the public. Disclosures, however, will only be made to someone who may be able to help prevent the threat.
BUSINESS ASSOCIATES: We may disclose PHI to our business associates that provide functions on our behalf or provide us with services if the PHI is necessary for such functions or services. All of our business associates are obligated to protect the privacy of your PHI and are not allowed to use or disclose PHI other than is specified in our contract.
MILITARY & VETERANS: If you are a member of the armed forces, we may use PHI as required by military command authorities.
WORKERS’ COMPENSATION: We may release PHI for workers’ compensation or similar programs. These programs provide benefit for workrelated injuries or illnesses.
PUBLIC HEALTH RISKS: We may disclose PHI for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births or deaths; report communicable or sexually transmitted diseases; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition; and the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
HEALTH OVERSIGHT ACTIVITIES: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include but are not limited to investigations, audits, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
LEGAL MATTERS: If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the PHI requested.
LAW ENFORCEMENT: We may release PHI if requested by a law enforcement official if the PHI is in response to a court order, subpoena, warrant, summons or similar process; limited information to identify or locate a suspect, fugitive, material witness or missing person; about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; about a death we may believe may be a result of criminal conduct; about criminal conduct on our premises; and in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.
INFORMATION NOT PERSONALLY IDENTIFIABLE: We may use or disclose PHI about you in a way that does not personally identify you or reveal who you are.
OTHER USES AND DISCLOSURES: We will not use or disclose your PHI for any purpose other than those described in the previous sections without your specific authorization. We must obtain your authorization separate from any consent we may have obtained by you. If you have given us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use or disclose your PHI for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.
In Illinois, a specific written authorization (different than the authorization and consent mentioned above) is required to disclose or release records of mental health treatment, alcoholism treatment, drug abuse treatment or HIV/AIDS treatment information. We do not use or disclose PHI for marketing purposes or research activities.
RIGHT TO INSPECT & RECEIVE COPY: You have the right to inspect and receive a copy of PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records. To inspect and receive a copy of this PHI you must send a written request to our Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. If you request a copy of this PHI we may charge a fee as allowed by Illinois law. We may deny your request in certain limited circumstances. You may ask that the denial be reviewed. If such a review is required, by law we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome review. RIGHT TO AMEND: If you feel the current PHI we have is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must make your request, in writing, to Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. We may deny your request as permitted by law.
RIGHT TO AN ACCOUNTING OF DISCLOSURES.
You have the right to request a list of certain disclosures we made of PHI for purposes other than treatment, payment and health care operations. To request an accounting of disclosures, you must make your request, in writing, to Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. We may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
RIGHT TO REQUEST RESTRICTIONS.
You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. We are not required to agree to your request. If we agree, we will comply with your request unless PHI is needed to provide you with emergency treatment.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request, in writing, to Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
RIGHT TO A PAPER COPY OF THIS NOTICE.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website www.blueseasmedspa.com. To obtain a paper copy of this notice, ask any of our office personnel by calling 8476818821.
CHANGES TO THIS NOTICE.
We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page underneath the title of this document.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Medical Director, FreshSkin, 595 Elm Place, Suite 208, Highland Park, IL 60035. All complaints must be in writing. You will not be penalized for filing a complaint.
Notice of Privacy Practices Rev 5/20/16