THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION AS REQUIRED BY THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT OF 1996 (HIPPA).”
PLEASE REVIEW IT CAREFULLY.
Statement of Uses and Disclosures: The Notice includes the
following:
• The types of uses and disclosures that the practice is
permitted to make under the Privacy Rule for treatment,
payment, and health care operations;
• The other purposes for which the Privacy Rule permits or
requires the practice to use or disclose PHI without the
individual's written authorization;
• A description of any material limitations or prohibitions
imposed by State or other applicable law on permitted uses
and disclosures beyond that outlined in the first two dot
points;
• Sufficient detail in each description to place the
individual on notice of the uses and disclosures that are
permitted or required by the Privacy Rule and other
applicable law; and
• A statement that other uses and disclosures will be made
only with written authorization and that the individual may
revoke such authorization.
In addition, the practice includes a statement that the
practice will/will not contact the individual with
appointment reminders or information about treatment
alternatives or other health-related benefits and services
that may be of interest to the individual.
Individual Rights: The Notice contains a description of the
individual rights granted under the Privacy Rule:
• The right to receive confidential PHI communications of
PHI;
• The right to inspect, copy and request amendment of PHI;
and
• The right to receive an accounting of PHI disclosures.
The practice allows individuals to request restrictions on
the use and disclosure of PHI, and evaluates the request on
an individual basis.
The Notice states that the practice may not limit its
obligation to make a use or disclosure that either the law
requires or the Privacy Rule permits to prevent or lessen a
serious and imminent threat to a person’s or public health
or safety.
Duties of the Practice: The Notice outlines the practice’s
duties, including that the law requires the practice to:
• Maintain the privacy of PHI and provide individuals with
notice of the practice’s legal duties and privacy practices
with respect to PHI;
• Abide by the terms of the Notice currently in effect; and
• Include a statement that the practice reserves the right
to change the terms of its notice and to make the new notice
provisions effective for all PHI that it maintains. When
this occurs, the practice provides individuals with a
revised notice at the patient’s next visit or informs them
of how to obtain a revised notice.
Complaints: The Notice explains that individuals may
complain to the practice’s privacy officer and to the HHS
Secretary, if they believe their privacy rights have been
violated. In addition, the Notice indicates how the
individual may file a complaint and that the practice will
not retaliate against any individual that files a complaint.
Contact: The Notice will contain the title, and telephone
number of a person or office to contact for further
information. That person is the practice’s privacy officer. Barbara M. Sokolowski
Practice Manager
909 East Palatine Road
Palatine, Illinois 60074
(847) 776-1400
Effective Date: The Notice contains an effective date,
which is not earlier than the date on which the notice is
published. The practice’s initial notice was effective April
14, 2003.
Revisions to the Notice: The practice will promptly revise
and provide its Notice whenever there is a material change
to the uses or disclosures, the individual's rights, the
covered entity's legal duties, or other privacy practices
stated in the Notice. Except when required by law, a
material change to any term of the Notice will not be
implemented prior to the effective date of the notice in
which such material change is reflected.
Documentation:
The practice documents compliance with the Notice
requirements by retaining copies of each of its Notices of
Privacy Practices. Copies of the “Receipt of Notice of
Privacy Practices” forms are maintained in each patient’s
medical record. Copies of materials will be retained as
required for a period of six years from the date of
creation. |