Southern Illinois Healthcare Foundation, Inc.
Privacy Notice
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the Privacy Officer
at (618) 397-3303.
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WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by our employees,
staff and other office personnel. The practices described in this notice will also
be followed by health care providers you consult with by telephone (when your regular
health care provider from our office is not available) who provide "call coverage"
for your health care provider.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health
status, and the health care and services you receive at this office.
We are required by law to give you this notice. It will tell you about the ways
in which we may use and disclose health information about you and describes your
rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: We may use health information
about you to provide you with medical treatment or services. We may disclose health
information about you to doctors, nurses, technicians, office staff or other personnel
who are involved in taking care of you and your health.
Different personnel in our office may share information about you and disclose information
to people who do not work in our office in order to coordinate your care, such as
phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays.
Family members and other health care providers may be part of your medical care
outside this office and may require information about you that we have.
For Payment: We may use and disclose health
information about you so that the treatment and services you receive at this office
may be billed to and payment may be collected from you, an insurance company or
a third party. For example, we may need to give your health plan information about
a service you received here so your health plan will pay us or reimburse you for
the service. We may also tell your health plan" about a treatment you are going
to receive to obtain prior approval, or to determine whether your plan will cover
the treatment.
For Health Care Operations: We may use and
disclose health information about you in order to run the office and make sure that
you and our other patients receive quality care. We may call you by name in the
waiting room when the doctor is ready to see you.
Appointment Reminders: We may contact you as
a reminder that you have an appointment for treatment or medical care at the office.
Treatment Alternatives: We may tell you about
or recommend options or alternatives that may be of interest to you.
Health-Related Products and Services: We may use private
health information to tell you about health-related products or services that may
be of interest to you.
SPECIAL SITUATIONS
We may use or disclose health information about you without your permission for
the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety: We
may use and disclose health information about you when necessary to prevent a serious
threat to your health and safety or the health and safety of the public or another
person.
Required By Law: We may disclose health information
about you when required to do so by federal, state or local law.
Research: We may use and disclose health information
about you for research projects that are subject to a special approval process.
We will ask you for YOllr permission if the researcher will have access to your
name, address or other information that reveals who you are, or will be involved
in your care at the office.
Organ Tissue Donation: If you are an organ donor,
we may release health information to organizations that handle organ procurement
or organ, eye or tissue transplantation or to an organ donation bank, as necessary
to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence:
If you are or were a member of the armed forces, or part of the national security
or intelligence communities, we may be required by military command or other government
authorities to release health information about you. We may also release information
about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation: We may release health information
about you for workers' compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
Public Health Risks: We may disclose health information
about you for public health reasons in order to prevent or control disease, injury
or disability; or report births, deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications or problems with products.
Health Oversight Activities: We may disclose health
information to a health oversight agency for audits, investigations, inspections
or licensing purposes. These disclosures may be necessary for certain state and
federal agencies to monitor the health care system, government programs, and compliance
with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit
or a dispute, we may disclose health information about you in response to a court
or administrative order. Subject to all applicable legal requirements, we may also
disclose health information about you in response to a subpoena.
Law Enforcement: We may release health information
if asked to do so by a law enforcement official in response to court order, subpoena,
warrant, summons or similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners and Funeral Directors:We may
release health information to a coroner or medical examiner. This may be necessary,
for example, to identify a deceased person or determine the cause of death.
Information Not Personally Identifiable:We may use or disclose
health information about you in a way that does not personally identify you or reveal
who you are.
Family and Friends: We may disclose health information
about you to your family members or friends if we obtain your verbal agreement to
do so or if we give you an opportunity to object to such a disclosure and you do
not raise an objection. We may also disclose health information to your family or
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 our disclosure
of your personal health information to your spouse when you bring your spouse with
you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present
or due to your incapacity or medical emergency), we may, using our professional
judgment determine that a disclosure to your family member or friend is in your
best interest. In that situation, we will disclose only health information relevant
to the person's involvement in your care. For example, we may inform the person
who accompanied you to the emergency room that you suffered a heart attack and provide
updates on your progress and prognosis. We may also use our professional judgment
and experience to make reasonable inferences that it is in your best interest to
allow another person to act on your behalf to pick up, for example, filled prescriptions,
medical supplies, or X-rays.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those
identified in the previous sections without your specific, written Authorization.
We must obtain your Authorization separate from any Consent we may have obtained
from you. If you give us Authorization to use or disclose health information about
you, you may revoke that Authorization, in writing, at any time. If you revoke your
Authorization, we will no longer use or disclose information about you for the reasons
covered by your written Authorization, but we cannot take back any uses or disclosures
already made with your permission.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy: You may have the right to inspect
and copy your health information, such as medical and billing records, that we use
to make decisions about your care. You must submit a written request to (the Privacy
Officer) in orderto inspect and/or copy your health information. If you request
a copy of the information, we may charge a fee of the costs of copying, mailing
or other associated supplies. We may deny your request to inspect and/or copy in
certain limited circumstances. If you are denied access to your health information,
you may ask that the denial be reviewed. If such a review is required by law, we
will select a licensed health care 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 of the review.
Right to Amend: If you believe health information we have
about you is incorrect or incomplete, you may ask us to amend to the information.
To request an amendment, complete and submit a Medical Record Amendment/Correction
Form to (the Privacy Officer). We may deny your request for an amendment if it is
not in writing or does not include a reason to support the request. In addition,
we may deny your request if you ask us to amend information that:
a) We did not create, unless the person or entity that created the information is
no longer available to make the amendment.
b) Is not part of the health information that we keep.
c) You would not be permitted to inspect and copy.
d) Is accurate and complete.
Right to an Accounting of Disclosures:You have the right
to request and "accounting of disclosures." This is a list of the disclosures
we made of medical information about you for purposes other than treatment, payment
and health care operations. Your request must state a time period, which may not
be longer than six years and may not include dates before April 14, 2003. We may
charge you for the costs of providing the list. We will notify you of the cost 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 health information we use or disclose about you
for treatment, payment or health care operations.
You also have the right to request a limit on the health information we disclose
about you to someone who is involved in your care or the payment for it, like a
family member or friend. For example, you could ask that we not use or disclose
information about a surgery you had.
We are Not Required to Agree to Your Request: If we do agree,
we will comply with your request unless the information is needed to provide you
emergency treatment.
To request restrictions, you may complete and submit the Request For Restriction
On Use/Disclosure Of Medical Information to (the Privacy Officer).
Right to Request Confidential Communications: 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
at work or by mail.
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. To obtain such a copy, contact (the Privacy Officer).
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice
effective for medical information we already have about you as well as any information
we receive in the future. You are entitled to a copy of the notice currently in
effect.
COMPLAINTS
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 (Privacy Officer, Southern Illinois
Healthcare Foundation, Executive Office, 8080 State Street, E. St. Louis, IL 62203,
(618) 397-3303. You will not be penalized for filing a complaint.
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION will not hold against you or retaliate
in any manner for filing a complaint regarding you privacy rights.
This privacy notice is effective as of April 14, 2003.
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