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Notice of Privacy Practices


Purpose of This Notice
This notice tells you about how we use and disclose your medical information. It tells you about your rights and our responsibilities to protect the privacy of your medical information. It also tells you how to complain to us, or the government if you believe that we violated any of your rights or any of our responsibilities.

We are required by law to maintain the privacy of your medical information. We must provide you with a copy of this notice and get your written acknowledgement of its receipt.

We must follow the terms of this notice that are currently in effect. We will tell you if we change this notice. A copy of the revised notice will be available upon request or posted at our location or on our website. We may change our practices and those changes may apply to medical information we already have about you as well as any new information.

This notice will be given to you on the date that you first receive medical products or treatment from a Covered Entity.

In an emergency, we will give you the notice as soon as possible after the emergency treatment has been given.

How We Use or Disclose Your Medical Information For Treatment
We will use medical information about you to provide you with treatment and services. We may share this information with members of our healthcare staff or with others involved in your care such as doctors, nurses or Healthcare facilities. For example, a nurse who is providing your care will report any changes in your condition to your doctor. We may also disclose your health information to a member of your family or other person who is involved in your care.

For Payment
We may use or disclose your medical information to bill and collect payment for the services we provided to you. For example, we may need to give your health insurance plan information about your diagnosis, treatment and supplies used. We may also contact your insurance plan to confirm your coverage or to request prior approval for a planned treatment or service.

Healthcare Operations
We may use of disclose your medical information for operational purposes. For example, we may use your medical information to evaluate our services, including the performance of our staff in caring for you. We may also use this information to learn how to continually improve the quality and effectiveness of the healthcare services that we provide to you.

Common Disclosure for Treatment, Payment or Healthcare Operations
Your name and address may be used to send out patient satisfaction surveys.  We may contact you either by telephone or by mail at your Covered Entity, home or office to remind you of an appointment that you have with us or any other matter related to healthcare services we provide or payment for your healthcare services. We may leave messages for you also. If you want us to contact you in a certain way or at a certain location, see “Right to Receive Confidential Communications” in this notice.

There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we will have a written contract with them that requires that they protect the privacy of your medical information.

Other Use and Disclosure of Your Medical Information

Individuals involved in your care – We may disclose medical information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may also use of disclose medical information about you to notify those persons of your location, general condition or death. Of there is a family member, other relative or close friend to whom you do not want us to disclose your medical information to, please notify our Designee in writing.

Use or Disclosure That are required or Permitted by Law.

Disaster Relief – We may use of disclose medical information about you to assist in disaster relief efforts. This will be done to notify family members or others or your location, general condition or death in the event of a natural or man-made disaster.

Required by Law – We may use or disclose medical information about you when we are required to do so by law.

Communicable Diseases – We may disclose your medical information to a person who may have been exposed to an infectious disease or who is at risk of spreading the disease or condition.

Public health Activities – We may disclose medical information about you for public health activities to prevent or control disease.

Victims of Abuse, Neglect or Domestic Violence – We may disclose medical information about you to a government agency if we believe you are the victim of abuse, neglect or domestic violence.

Health Oversight Activities – We may disclose medical information about you to a health oversight agency.

Food and Drug Administration – We may disclose medical information about you to monitor drugs or devices controlled by the Food and Drug Administration.

Legal Activities – We may disclose medical information about you in response to a court proceeding. We may also disclose medical information about you in response to a subpoena or other legal process.

Disclosures for Law Enforcement Purposes – We may disclose information about you to law enforcement officials for law enforcement purposes:

  • As required by law.
  • In response to a court order or other legal proceeding.
  • To identify or locate a suspect, fugitive, material witness or missing person.
  • When information is requested about an actual or suspected victim of a crime.
  • To report a death as a result of possible criminal conduct.
  • About crimes that occur on our premises.
  • To report a crime in emergency circumstances.

Funeral Directors, Coroners and Medical Examiners – We may disclose medical information about you as necessary to allow these individuals to carry out their responsibilities.

Organ Donation – We may disclose medical information about you to organ procurement organizations if you are an organ donor.

Workers’ Compensation – We may disclose medical information about you to comply with workers’ compensation laws that provide benefits for work-related injuries or illnesses.

Public Health or Safety – We may use or disclose medical information about you if we feel it is necessary to prevent a threat to the health or safety of a person or the general public.

Military – If you are a member of the Armed Forces, we may use and disclose medical information about you to you military command.

National Security and Intelligence – We may disclose medical information about you to authorized federal officials for national security and intelligence activities.

Security Clearance – We may use medical information about you for required security clearance.

Inmates – We may disclose medical information about you to a correctional institution or law enforcement official that has custody of you.

Research – We may disclose your medical information to researchers under certain limited circumstances.

Uses or Disclosures that Require Your Authorization.
Other uses and disclosures will be made only with your written authorization. You may cancel an authorization at anytime by notifying Our Designee in writing of your desire to cancel it. If you cancel an authorization it will not have any affect on information that we have already disclosed.

Examples of uses or disclosures that may require you written authorization include the following:

  • A request to provide certain medical information to a drug company for marketing purposes.
  • A request to provide your medical information to an attorney for use in a civil law suit.

Your Rights
The information contained in your health or medical record is the physical property of your Covered Entity. The information in it belongs to you. You have the following rights:

Right to Request Restrictions – You have the right to ask us not to use or disclose your medical information for a particular reason related to treatment, payment or ouroperations. You may ask that family members or other individuals not be informed of specific medical information.

That request must be made in writing to Our Designee. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. Either you or your Covered Entity can stop a restriction at any time.

Right to receive Confidential Communications – You have the right to ask that we communicate with you in a certain manner or at a certain place. If you want to requestconfidential communications the request must be made in writing to Our Designee. We must agree to your request if it is reasonable.

Right to Inspect and Copy Your Medical Information – You have the right to request to inspect and obtain a copy of your medical information. You must submit your request in writing to Our Designee. If you request a copy of the information or we provide you with a summary of the information we may charge a fee for the costs of copying, summarizing and/or mailing it to you.

If we agree to your request we will tell you. We may deny your request under certain limited circumstances. If your request is denied, we will let you know in writing and you may be able to request a review of our denial.

Right to Request Amendments to Your Medical Information – You have the right to request that we correct your medical information. If you believe that any medicalinformation in your record is incorrect or that important information is missing, you must submit your request for an amendment in writing to Our Designee.  We do have to agree to your request. If we deny your request we will tell you why. You have the right to submit a statement disagreeing with our decision. We may deny your request if we determine that the information:

  • was not created by us.
  • is not part of the medical information that we maintain.
  • is in records that you are not allowed to inspect and copy.
  • is already accurate or complete.

Right to an Accounting of Disclosures of Health

Information – You have the right to find out what disclosures of your medical information have been made. The list of disclosures is called an accounting. The accounting may be for up to six (6) years prior to the date on which you request the accounting, but cannot include disclosures before April 14, 2003.

We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions.

Requests for an accounting of disclosures must be submitted in writing to Our Designee. You are entitled to one free accounting in any twelve (12) month period. We may charge you for the cost of providing additional accountings. If there will be a charge for additional accountings we will notify you in advance.

Right to Obtain a Copy of the Notice – You have the right to request and get a paper copy of this notice and any revisions we make to the notice at any time.

You have the right to complain to us and to the United States Secretary of Health and Human Services, if you believe we have violated your privacy rights. There is no risk in filing a complaint.

To file a complaint with us contact by phone or by mail:

Our Designee: Chief Greg Formica

Address Information:

409 W Nippersink Road
Round Lake, IL 60073

Telephone Number: (847) 546-6001

To file a complaint with the United States Secretary of Health and Human Services send your complaint to him or her in care of:

Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201

Questions and Information
If you have any questions or want more information about this notice of Privacy Practices, please contact:

Our Designee: Chief Greg Formica


409 W Nippersink Road
Round Lake, IL 60073

Telephone Number: (847) 546-6001

You can contact Our Designee by phone with questions or complaints or with written requests for information as defined under the Your Rights section of this notice.

The current effective date of this Privacy Notice is:  April 14, 2003.