Your Privacy

NOTICE OF PRIVACY PRACTICES

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.

We are required by law to maintain the privacy of protected health information (PHI) and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are also required to abide by the terms of this Notice.

We reserve the right to make changes to this Notice and any changes will apply to PHI that is already in our possession. If and when this Notice is changed, we will post a copy of the changed Notice in our office in a prominent location and provide you with a copy upon request.

A. WE ARE PERMITTED UNDER FEDERAL LAW TO MAKE THE FOLLOWING USES OR DISCLOSURES OF YOUR PHI WITHOUT YOUR AUTHORIZATION:

To You. We may disclose your PHI to you or to your personal representative.

Treatment. We may use or disclose your PHI to provide you with medical treatment. For example, we may disclose your PHI to doctors, nurses, pharmacists, technicians, medical students or other health care providers or personnel who are involved in taking care of you.

Payment. We may use and disclose PHI to bill and collect payment for the treatment and services you receive from us. For example, we may need to provide your health plan or insurance company with information about a treatment or service we performed for you.

Health Care Operations. We may use and disclose PHI in the course of performing activities called “health care operations." For example, we may use your PHI to perform business management and general administrative activities of our practice, including managing our activities related to complying with the HIPAA Privacy Rule.

Appointment Reminders; Treatment Alternatives. We may use and disclose PHI to remind you of an appointment, or to tell you about possible treatment alternatives or other health-related benefits and services that may be of interest to you.

Required By Law. We may use and disclose PHI as required by federal, state, or local law as long as any disclosure complies with the law and is limited to the requirements of the law.

Public Health Activities. We may use or disclose PHI to public health authorities or other persons authorized to carry out certain activities related to public health, such as to report disease, injury, birth or death or to report child abuse or neglect, or to notify a person who may have been exposed to a communicable disease in order to control the spread of the disease.

Abuse, Neglect or Domestic Violence. We may disclose PHI in certain cases to proper government authorities if we reasonably believe that a patient has been a victim of domestic violence, abuse or neglect.

Health Oversight Activities. We may disclose PHI to a health oversight agency in connection with audits, investigations, inspections and other activities it undertakes to monitor the health care system, government health care programs and compliance with certain laws.

Lawsuits and Other Legal Proceedings. We may use or disclose PHI when required by a court or administrative tribunal.

Law Enforcement. Under certain conditions, we may disclose PHI to law enforcement officials for the purpose of reporting or investigating criminal activity.

Coroners, Medical Examiners, Funeral Directors. Under certain conditions, we may disclose PHI to a coroner, medical examiner, or to funeral directors.

Organ and Tissue Donation. Under certain circumstances, we may use or disclose PHI in order to facilitate an organ, eye or tissue donation and transplantation.

Research. With permission from an Institutional Review Board, we may be permitted to use and disclose your PHI for research purposes. We may also disclose limited portions of your PHI if we receive written assurances that the recipient will safeguard the information.

To Avert a Serious Threat to Health or Safety. We may use or disclose PHI about you in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public.

Specialized Government Functions. We are permitted to disclose PHI for certain military and veteran activities, for national security and intelligence activities, for the health or safety of people in correctional institutions, and for certain public benefit programs.

Disclosures Required by HIPAA Privacy Rule. We are required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA Privacy Rule.

Workers? Compensation. We may disclose PHI as authorized by workers? compensation laws or other similar programs that provide benefits for work-related injuries or illness.

Business Associates. We may disclose PHI to individuals or entities that perform services for us if we obtain written assurances that they will safeguard the information.

Marketing and Fundraising. We may use and disclose PHI for marketing and fundraising purposes in certain limited circumstances.

Individuals Involved in Your Care or Payment. We may disclose PHI about you to people involved in your care or payment for your care if we have your verbal agreement, or if you have the opportunity to object but do not. If you are not present or you are unable to consent or object, we may exercise professional judgment in determining whether the use or disclosure of PHI is in your best interests.

ALL OTHER USES AND DISCLOSURES OF PHI ABOUT YOU THAT ARE NOT MENTIONED ABOVE, MAY ONLY BE MADE WITH YOUR WRITTEN AUTHORIZATION, WHICH MAY BE REVOKED AS PROVIDED IN 45 CFR 164.508(b)(5).

B. YOU HAVE THE FOLLOWING RIGHTS REGARDING YOUR PHI:

Right to Request Restrictions. You have the right to request additional restrictions on certain uses and disclosures of your PHI by contacting our Privacy Officer as provided below, but we are not required to agree to your request.

Right to Receive Confidential Communications. You have the right to receive communications regarding PHI in a reasonable alternative manner or location. You must make your request in writing to our Privacy Officer.

Right to Inspect and Copy. You have the right to inspect and receive a copy of PHI that may be used to make decisions about your care by submitting your request in writing to our Privacy Officer.

Right to Request Amendment. If you feel that your PHI is incorrect or incomplete, you have the right to request that we amend it by submitting your request in writing to our Privacy Officer.

Right to Receive an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures that we have made of your PHI by submitting your request in writing to our Privacy Officer.

Right to a Paper Copy of this Notice. You have a right to receive a paper copy of this Notice at any time, even if you have previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact our Privacy Officer.

Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the United States Department of Health and Human Services. To file a complaint with our office, please contact our Privacy Officer at the address and number listed below. We will not retaliate or take action against you for filing a complaint. All complaints must be submitted in writing.

Questions. If you have any questions about this Notice, please contact our Privacy Officer at 973 Featherstone Road, Suite 100, Rockford IL 61107 or (815) 986-3757.

THIS NOTICE BECOMES
EFFECTIVE ON APRIL 14, 2003

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Rockford:
973 Featherstone Road
Suite 100
Rockford, IL 61107
Toll-free: 877-373-7552
Fax: 815-986-3748


Peoria:
900 Main Street
Suite 330

Peoria, IL 61602
Toll-free: 877-373-7552
Fax: 815-986-3748

Peru:
920 West Street, Bldg B
Peru, IL 61354
Toll-free: 877-373-7552
Fax: 815-986-3748

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