Notice of Privacy Practices
Town & Country Pediatrics, S.C., Notice of Privacy Practices – Effective October 5, 2012
As Required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 as amended (HIPAA), THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU AND YOUR CHILDREN (AS PATIENTS OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI). PLEASE REVIEW THIS NOTICE CAREFULLY.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. Our Commitment to your Privacy:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information. In conducting our business, we will create records regarding you and your children and the services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you or your children. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI.
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your IIHI
- Your privacy rights in your IIHI
- Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your children's IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. If you have questions about this notice, please contact Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279-8900. E-mail: firstname.lastname@example.org.
C. We may use and disclose your IIHI in the following ways:
- Treatment. We may use your child’s IIHI to treat your child. For example, we may ask your child to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might also use your child's IIHI in order to write a prescription for them. All of the permanent employees at Town & Country Pediatrics may use or disclose your child's IIHI to treat your child or assist other health care providers in their treatment. Additionally, we may disclose your child's IIHI to others who may assist in your child's care, such as your spouse or parents. We may also use and disclose your child’s IIHI to inform you of potential treatment options or alternatives. An example would be to refer you to a home healthcare agency.
- Payment. Our practice may use and disclose your child's IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your child's treatment. We also may use and disclose your child's IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your child’s IIHI to bill you directly for services and items. We may disclose your child's IIHI to other health care providers and entities to assist in their billing and collection efforts.
- Health Care Operations. Our practice may use and disclose your child's IIHI to operate our business. As an example, our practice may use your child's IIHI for the state and regulatory agencies to evaluate the quality of care you received from us.
- Health‐Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of health‐related benefits or services that may be of interest to you. Examples are free formula or pharmaceutical supply houses to procure expensive drugs such as Synagis.
- Release of Information to Family/Friends. Our practice may release your child’s IIHI to a friend or family member who is involved in your child's care, or who assists in taking care of your child. For example, a parent or guardian may ask that a babysitter or nanny take their child to our practice for treatment of a cold. In this case, we may disclose your child's IIHI to the babysitter or nanny.
- Disclosures Required by Law. Our practice will use and disclose your child's IIHI when we are required to do so by federal, state, or local law.
D. Use and Disclosure of Your Child's IIHI in Certain Special Circumstances.
Public Health Risks. Our practice may disclose your child's IIHI to public health authorities that are authorized by law to collect information for the purpose of:
- Maintaining vital records, such as births and deaths
- Reporting child abuse or neglect
- Preventing or controlling disease, injury, or disability
- Notifying a person regarding potential exposure to a communicable disease
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with products or devices
- Notifying individuals if a product or device they may be using has been recalled
Health Oversight Activities. Our practice may disclose your child's IIHI to a health oversight agency for activities authorized by law. Examples are: investigations, inspections, audits, surveys, licensure and disciplinary actions, civil administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
Lawsuits and Similar Proceedings. Our practice may use and disclose your child's IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding and in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain your agreement
- Concerning a death we believe has resulted from criminal conduct
- Regarding criminal conduct at our offices
- In response to a warrant, summons, court order, subpoena or similar legal process
- To identify/locate a suspect, material witness, fugitive or missing person
- In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.
Organ and Tissue Donation. Our practice may release IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if your child is an organ donor.
Serious Threats to Health or Safety. Our practice may use and disclose your child's IIHI when necessary to reduce or prevent a serious threat to their health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
E. Your Rights Regarding Your Child's IIHI
You have the following rights regarding the IIHI that we maintain about your child:
- Confidential Communications. You have the right to request that our practice communicate with you about your child's health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642, email email@example.com, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
- Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your child's IIHI for treatment, payment or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your child's IIHI to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat your child. In order to request a restriction in our use or disclosure of your child's IIHI, you must make a request in writing to Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail: firstname.lastname@example.org. Your request must describe in a clear and concise fashion:
- The information you wish restricted
- Whether you are requesting to limit our practice's use, disclosure or both; and
- To whom you want the limits to apply
- Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about your child, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail:email@example.com to inspect and/or obtain a copy of your child's IIHI. Our practice will charge a fee for the costs of copying, mailing, and labor/supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
- Amendment. You may ask us to amend your child's health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail: firstname.lastname@example.org. You must provide us with a reason that supports your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete, (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
- Accounting of Disclosures. All of our patients have the right to request an "accounting of disclosures. An "accounting of disclosures" is a list of certain non‐routine disclosures our practice has made of your IIHI for non‐treatment, non‐payment or non‐operations purposes. Use of your child's IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse or the billing department using your child's information to file your insurance claim. To obtain an accounting of disclosures, you must submit your request in writing Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642 or email to email@example.com. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12‐month period is free of charge, but our practice will charge you for an additional list within the same 12‐month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
- Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail: firstname.lastname@example.org. A copy of this notice is also located on our web site at www.townandcountrypeds.com.
- Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services or the Illinois Attorney General. To file a complaint with our practice, contact Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail: email@example.com. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
- Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You may revoke any authorization you provide to us regarding the use and disclosure of your child's IIHI at any time in writing. After you revoke your authorization, we will not longer use or disclose your IIHI for the reasons described in the authorization. Please note that we are required to retain records of your child's healthcare. Again, if you have any questions regarding this notice or our health information privacy policies, please contact, Privacy Officer, 1460 N. Halsted, Ste. 402, Chicago, IL 60642. Phone: (312) 279‐8900. E‐mail:firstname.lastname@example.org.