ELM CITY CENTER
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.
Effective Date: April 14, 2003.
We respect consumer
confidentiality and only release medical information about you in accordance
with the Illinois and federal law. This notice describes our policies
related to the use of the records of your care generated by this practice.
Privacy Contact - If you have any
questions about this policy or your rights contact President/CEO of Elm City
Center at 217-245-9504 or e-mail at
email@example.com. This Notice of Privacy Practices is specifically
designed for Health Insurance Portability And Accountability Act
(HIPAA) regulations. All
existing confidentialty agreements between Elm City Center and any other
organizations remain in effect.
Guardians - Many people
receiving services at Elm City are represented by legal guardians assigned
by the courts. At all times, any legal guardians representing people
receiving services at Elm City will have access to the procedures listed
below for the person they represent. Elm City will make every effort to
maintain current status on known guardianship relationships. Individuals
identifying themselves as a person's legal guardian may be asked to provide
written documentation if they or the legal status is not known to Elm City
AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
In order to effectively provide
you care, there are times when we will need to share your medical
information with others beyond our practice. This includes for:
Treatment. We may use or disclose
medical information about you to provide, coordinate, or manage your care
or any related services, including sharing information with others outside
our practice that we are consulting with or referring you to.
Payment. Information will be used
to obtain payment for the treatment and services provided. This will
include contacting your health insurance company for prior approval of
planned treatment or for billing purposes.
Healthcare Operations. We may use
information about you to coordinate our business activities. This may
include setting up your appointments, reviewing your care, training staff.
Without Your Consent.
Under Illinois and federal law, information about you may be disclosed
without your consent in the following circumstances:
information may be shared to address the immediate emergency you are
Follow Up Appointments/Care. We
will be contacting you to remind you of future appointments or information
about treatment alternatives or other health-related benefits and services
that may be of interest to you.
As Required by Law. This would
include situations where we have a subpoena, court order, or are mandated
to provide public health information, such as communicable diseases or
suspected abuse and neglect such as child abuse, elder abuse, or
Coroners, Funeral Directors, and
Organ Donation. We may disclose medical information to a coroner or
medical examiner and funeral directors for the purposes of carrying out
their duties. When organs are donated sufficient information will be
provided to the program as necessary to facilitate the organ or tissue
Governmental Requirements. We may
disclose information to a health oversight agency for activities
authorized by law, such as audits, investigations inspections and
licensure. There also might be a need to share information with the Food
and Drug Administration related to adverse events or product defects. We
are also required to share information, if requested with the Department
of Health and Human Services to determine our compliance with federal laws
related to health care.
Criminal Activity or Danger to
Others. If a crime is committed on our premises or against our personnel
we may share information with law enforcement to apprehend the criminal.
We also have the right to involve law enforcement when we believe an
immediate danger may occur to someone.
Fundraising. As a not for profit
provider of health care services we need assistance in raising money to
carry out our mission. We may contact you to seek a donation
You have the following rights
under Illinois and federal law:
Copy of Record. You are entitled
to inspect you the medical record our practice has generated about you. We
may charge you a reasonable fee for copying and mailing your record.
Release of Records. You may
consent in writing to release of your records to others, for any purpose
you choose. This could include your attorney, employer, or others who you
wish to have knowledge of your care. You may revoke this consent at any
time, but only to the extent no action has been taken in reliance on your
Restriction on Record. You may
ask us not to use or disclose part of the medical information. This
request must be in writing. The Practice is not required to agree to your
request if we believe it is in your best interest to permit use and
disclosure of the information. The request should be given to the
Contacting You. You may request
that we send information to another address or by alternative means. We
will honor such request as long as it is reasonable and we are assured it
is correct. We have a right to verify that the payment information you are
providing is correct. We also will be glad to provide you information by
email if you request it. If you wish us to communicate by email you are
also entitled to a paper copy of this privacy notice.
Amending Record. If you believe
that something in your record is incorrect or incomplete, you may request
we amend it. To do this contact the
and ask for the
Request to Amend Health
Information form. In
certain cases, we may deny your request. If we deny your request for an
amendment you have a right to file a statement you disagree with us. We
will then file our response and your statement and our response will be
added to your record.
Accounting for Disclosures. You
may request an accounting of any disclosures we have made related to your
medical information, except for information we used for treatment,
payment, or health care operations purposes or that we shared with you or
your family, or information that you gave us specific consent to release.
It also excludes information we were required to release. To receive
information regarding disclosure made for a specific time period no longer
than six years and after April 14, 2003, please submit your request in
writing to our
Privacy Contact. We
will notify you of the cost involved in preparing this list.
Questions and Complaints. If you
have any questions, or wish a copy of this Policy or have any complaints
you may contact our
in writing at our office further
information. You also may complain to the Secretary of Health and Human
Services if you believe Elm City Center has violated your privacy rights.
We will not retaliate against you for filing a complaint.
- Changes in Policy. Elm
needs of Elm City Center and changes in state and federal law.