Retina Services of Illinois, LLC 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.
Effective Date of this Privacy Notice: September 23, 2013
We are required by law to protect the privacy of health information that may reveal your identity. We are also required by law to provide you with a copy of this Privacy Notice which describes our legal duties and health information privacy practices, as well as the rights you have with respect to your health information.
How We May Change our Notice of Privacy Practices
We may change our privacy practices from time to time. If we make any material revisions to this Privacy Notice, we will provide you with a copy of the revised Privacy Notice which will specify the date on which such revised Privacy Notice becomes effective. The revised Privacy Notice will apply to all of your health information from and after the date of the Privacy Notice.
How We May Use and Disclose Your Health Information
Without Written Authorization
Retina Services of Illinois, LLC requires its employees to follow its privacy and security policies and procedures to protect your health information in oral (for example, when discussing your health information with authorized individuals over the telephone or in person), written or electronic form. The following are situations where we do not need your written authorization to use your health information or to share it with others.
1. Treatment, Payment, and Business Operations. We may use your health information or share it with others to help treat your condition, coordinate payment for that treatment, and run our business operations. For example:
Treatment. We may use your health information to provide you with medical treatment or services. We may disclose your health information to doctors, nurses, or other hospital personnel involved in taking care of you.
Payment. We may use and disclose your health information so that providers from whom you receive treatment and services may receive payment. Examples of payment activities include: billing, claims management and other related administrative functions.
Health Care Operations. We may also disclose your health information in connection with our health care operations. These include fraud and abuse detection and compliance programs, customer service and resolution of internal grievances.
Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives, as well as health-related benefits or services that may be of interest to you.
Family Members, Relatives or Close Friends Involved In Your Care. Unless you object, we may disclose your health information to your family members, relatives or close personal friends identified by you as being involved in your treatment or payment for your medical care. If you are not present to agree or object, we may exercise our professional judgment to determine whether the disclosure is in your best interest. If we decide to disclose your health information to your family member, relative or other individual identified by you, we will only disclose the health information that is relevant to your treatment or payment.
Business Associates. We may disclose your health information to a “business associate” that needs the information in order to perform a function or service for our business operations. We will do so only if the business associate signs an agreement to protect the privacy of your health information. Third party administrators, auditors, lawyers, and consultants are some examples of business associates.
2. Public Need. We may use your health information, and share it with others, in order to comply with the law or to meet important public needs that are described below:
• if we are required by law to do so;
• to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities;
• to government agencies authorized to conduct audits, investigations, and inspections, as well as civil, administrative or criminal investigations, proceedings, or actions, including those agencies that monitor programs such as Medicare and Medicaid;
• to a public health authority if we reasonably believe you are a possible victim of abuse, neglect or domestic violence;
• to a person or company that is regulated by the Food and Drug Administration for: (i) reporting or tracking product defects or problems, (ii) repairing, replacing, or recalling defective or dangerous products, or (iii) monitoring the performance of a product after it has been approved for use by the general public;
• if ordered by a court or administrative tribunal to do so, or pursuant to a subpoena, discovery or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure;
• to law enforcement officials to comply with court orders or laws, and to assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public, which we will only share with someone able to help prevent the threat;
• for research purposes;
• to the extent necessary to comply with workers’ compensation or other programs established by law that provide benefits for work-related injuries or illness without regard to fraud;
• to appropriate military command authorities for activities they deem necessary to carry out their military mission;
• to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials;
• to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined;
• in the unfortunate event of your death, to a coroner or medical examiner, for example, to determine the cause of death;
• to funeral directors as necessary to carry out their duties; and
• in the unfortunate event of your death, to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under law.
3. Completely De-Identified and Partially De-Identified Information. We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” health information about you for public health and research purposes, or for business operations, if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, Social Security number, phone number, fax number, electronic mail address, Web site address, or license number).
Requirement for Written Authorization
We may use your health information for treatment, payment, health care operations or other purposes described in this Privacy Notice. You may also give us written authorization to use your health information or to disclose it to anyone for any purpose. We cannot use or disclose your health information for any reason except those described in this Privacy Notice unless you give us a written authorization to do so. For example, we require your written authorization for most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures of health information for marketing purposes, and disclosures that constitute a sale of your health information. Marketing is a communication about a product or service that encourages recipients of the communication to purchase or use the product or service.
You may revoke your authorization in writing at any time. We can provide you with a form revocation or you can write to us at the addresses listed on the last page of this Privacy Notice. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Your Rights to Access and Control Your Health Information
We want you to know that you have the following rights to access and control your health information.
1. Right to Access Your Health Information.
You have the right to inspect and obtain a copy of your health information except for health information: (i) contained in psychotherapy notes; (ii) compiled in anticipation of, or for use in, a civil, criminal, or administrative proceeding; and (iii) with some exceptions, information subject to the Clinical Laboratory Improvements Amendments of 1988 (CLIA). If we use or maintain an electronic health record (EHR) for you, you have the right to obtain a copy of your EHR in electronic format. You also have the right to direct us to send a copy of your EHR to a third party you clearly designate.
If you would like to access your health information, please send your written request to the address listed on the last page of this Privacy Notice. We will ordinarily respond to your request within 30 days. If we need additional time to respond, we will let you know as soon as possible. We may charge you a reasonable, cost-based fee to cover copy costs and postage. If you request a copy of your EHR, we will not charge you any more than our labor costs in producing the EHR to you.
We may not give you access to your health information if it:
(i) is reasonably likely to endanger the life and physical safety of you or someone else as determined by a licensed health care professional;
(ii) refers to another person and a licensed health care professional determines that your access is likely to cause harm to that person; or
(iii) a licensed health care professional determines that your access as the representative of another person is likely to cause harm to that person or any other person.
If you are denied access for one of these reasons, you are entitled to a review by a health care professional, designated by us, who was not involved in the decision to deny access. If access is ultimately denied, you will be entitled to a written explanation of the reasons for the denial.
2. Right to Amend Your Health Information.
If you believe we have health information about you that is incorrect or incomplete, you may request in writing an amendment to your health information. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after we receive your request. If we did not create your health information or your health information is already accurate and complete, we can deny your request and notify you of our decision in writing. You can also submit a statement that you disagree with our decision, which we can rebut. You have the right to request that your original request, our denial, your statement of disagreement, and our rebuttal be included in future disclosures of your health information.
3. Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your health information made by us and our business associates. You may request such information for the six-year period prior to the date of your request. Accounting of disclosures will not include disclosures:
(i) for payment, treatment or health care operations;
(ii) made to you or your personal representative;
(iii) you authorized in writing;
(iv) made to family and friends involved in your care or payment for your care;
(v) for research, public health or our business operations;
(vi) made to federal officials for national security and intelligence activities;
(vii) made to correctional institutions or law enforcement; and
(viii) incident to a use or disclosure otherwise permitted or required by law.
If you would like to receive an accounting of disclosures, please write to the address listed on the last page of this Privacy Notice. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after your request is received. You will receive one request annually free of charge, but we may charge you a reasonable, cost-based fee for additional requests within the same twelve-month period.
4. Right to Request Additional Privacy Protections. You have the right to request that we place additional restrictions on our use or disclosure of your health information. If we agree to do so, we will put these restrictions in place except in an emergency situation. We do not need to agree to the restriction unless (i) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and (ii) the health information relates only to a health care item or service that you or someone on your behalf has paid for out of pocket and in full. You have the right to revoke the restriction at any time.
5. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health information by alternative means or via alternative locations. If you wish to receive confidential communications via alternative means or locations, please submit your written request to the address listed on the last page of this Privacy Notice. You must clearly state in your request that the disclosure of your health information could endanger you and list how or where you wish to receive communications.
6. Right to Notice of Breach of Unencrypted Health Information. We are required by law to maintain the privacy of your health information, and to provide you with this Privacy Notice containing our legal duties and privacy practices with respect to your protected health information. Our policy is to encrypt our electronic files containing your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unencrypted health information, we will notify you of the breach. If we have more than ten people that we cannot reach because of outdated contact information, we will post a notification either on our Web site https://retinaservices.com/ or in a major media outlet in your area.
7. Right To Obtain A Paper Copy Of This Notice. You have the right at any time to obtain a paper copy of this Privacy Notice, even if you receive this Privacy Notice electronically. Please send your written request to the address listed on the last page of this Privacy Notice or visit our Web site at https://retinaservices.com/.
8. How to Learn About Special Protections for HIV, Alcohol, and Substance Abuse, Mental Health, and Genetic Information. Special privacy protections apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information. Some parts of this general Notice may not apply to these types of information. If your treatment involves this information, you will be provided with special authorization forms in connection with the disclosure of such information by the Hospital. To request copies of these forms, please contact the Privacy Officer at 847-972-2700.
Miscellaneous
1. Contact Information.
If you have any questions about this Privacy Notice, you may contact the Privacy Officer at 847-972-2700, visit https://retinaservices.com/, or write to us at:
Retina Services of Illinois, LLC
Attention: Privacy Officer
9933 Lawler Avenue
Suite 209
Skokie, IL 60077
2. Complaints.
If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information above. You also may submit a written complaint to the U.S. Department of Health and Human Services. If you choose to file a complaint, we will not retaliate or take action against you for your complaint.
3. Additional Rights.
This Privacy Notice explains the rights you have with respect to your health information, including access and amendment rights, under federal law. To the extent Illinois law affords you greater rights than described in this Privacy Notice, we will comply with these laws.
NOTICE OF PRIVACY PRACTICES FORM ACKNOWLEDGEMENT OF RECEIPT
Patient Name:_______________________________________________________________________________________
By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices of Retina Services of Illinois, LLC
________________________________________________ ________________________________________________
Print Name of Patient or Personal Representative Signature of Patient or Personal Representative
________________________________________________ ________________________________________________
Date Description of Personal Representative’s Authority
CONTACT INFORMATION
The contact information of the patient or personal representative who signed this form should be filled in below.
Address:_______________________________________________
Telephone:_____________________________________________ (Daytime) Evening__________________________________