Victor C. Neumann Association

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: April 14, 2003

We respect patient confidentiality and only release medical information about you in accordance with the Illinois and federal law. This notice describes our policies related to the use of the records of your care generated by this practice.

Privacy Contact

If you have any questions about this policy or your rights contact Donna Zurawski, LCSW, Director of Adult Clinical Services, at 773-506-3214.

Use And Disclosure Of Protected Health Information

In order to effectively provide you care, there are times when we will need to share your medical information with others beyond our practice. This includes for:

Treatment

We may use or disclose medical information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside our practice that we are consulting with or referring you to.

Payment

Information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes.

Healthcare Operations

We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.

Information Disclosed Without Your Consent

Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:

Emergencies

Sufficient information may be shared to address the immediate emergency you are facing.

Follow Up Appointments/Care

We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required by Law

This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.

Coroners, Funeral Directors, and Organ Donation

We may disclose medical information to a coroner or medical examiner and funeral directors for the purposes of carrying out their duties. When organs are donated sufficient information will be provided to the program as necessary to facilitate the organ or tissue donation.

Governmental Requirements

We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations inspections and licensure. There also might be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested with the Department of Health and Human Services to determine our compliance with federal laws related to health care.

Criminal Activity or Danger to Others

If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.

Fundraising

(This will only apply to not for profit providers. Delete if it does not apply to you). As a not for profit provider of health care services we need assistance in raising money to carry out our mission. We may contact you to seek a donation.

Patient Rights

You have the following rights under Illinois and federal law:

Copy of Record

You are entitled to inspect you the medical record our practice has generated about you. We may charge you a reasonable fee for copying and mailing your record.

Release of Records

You may consent in writing to release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Restriction on Record

You may ask us not to use or disclose part of the medical information. This request must be in writing. The Practice is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information. The request should be given to the Privacy Contact.

Contacting You

You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. We also will be glad to provide you information by email if you request it. If you wish us to communicate by email you are also entitled to a paper copy of this privacy notice. (Only add this last sentence if you do communicate by email.)

Amending Record

If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this contact the Privacy Contact and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.

Accounting for Disclosures

You may request an accounting of any disclosures we have made related to your medical information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request tin writing to our Privacy Contact. We will notify you of the cost involved in preparing this list.

Questions and Complaints

If you have any questions, or wish a copy of this Policy or have any complaints you may contact our Privacy Contact in writing at our office further information. You also may complain to the Secretary of Health and Human Services if you believe our Practice has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Policy

The Practice reserves the right to change its Privacy Policy based on the needs of the Practice and changes in state and federal law.