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.

This Notice of Privacy Practices describes how we may use and disclose your protected health/ personal information (PHI) to carry out treatment, payment or healthcare operations (TPO) and for other purposes that are permitted or required by law. It also describes our rights to access and control your protected information. “Protected health/ personal information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health/ Personal Information

Your protected health/ personal information may be used and disclosed by our medical director, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you to support business operations of this office, if requested by you to finance company to pay for your care, and any other use required by law.

Treatment: We will use and disclose your protected health/ personal information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health/ personal information, as necessary, if as, a result of our services, you require treatment by a physician. Your protected health/ personal information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health/ personal information will be used, if requested, to obtain payment for your services. For example, if you desire to finance the costs of your treatments, this may involve disclosing relevant protected private information in order to obtain approval.

Healthcare Operations: We may use or disclose, as needed, your protected health/ personal information in order to support the business activities of this office. These activities include, but are not limited to, quality assessment activities, employee, review activities, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health/personal information, as necessary, to contact you to remind you of your appointment.

We may also use or disclose your protected health/ personal information in the following situations without your authorization. These situations include: as required by law; public health issues as required by law, communicable diseases, health oversight, abuse or neglect; Food and Drug Administration requirements; legal processing; law enforcement; coroners, funeral directors or organ donation; research; criminal activity and national security; workers’ compensation; inmates; required uses and disclosures. Under the law, we must make disclosure to you and, when required by the Secretary of the U.S. Department of Health and Human Services, to investigate or determine our compliance with the requirements of the Standards for Privacy of Individually Identifiable Health Information set forth at 45 C.F.R parts 160 and 164.

Other permitted and required uses and disclosures will be made only with your written authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in the authorization.

5008 W Lawrence Ave      Chicago, IL 60630          (773) 205-8800         

Practice Policy