________________________________
We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to
give you this Notice about our privacy practices, our legal duties,
and your rights concerning your health information. We must follow
the privacy practices that are described in this Notice while it
is in effect. This Notice takes effect 04/14/2003, and will remain
in effect until we replace it.
We reserve the right to change our privacy practices and the terms
of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our
privacy practices and the new terms of our Notice effective for
all health information that we maintain, including health information
we created or received before we made the changes. Before we make
a significant change in our privacy practices, we will change this
Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information
about our privacy practices, or for additional copies of this Notice,
please contact us using the information listed at the end of this
Notice.
We use and disclose health information about you for treatment,
payment, and healthcare operations. For example:
: We may use or disclose your
health information to a physician or other healthcare provider providing
treatment to you.
: We may use and disclose your
health information to obtain payment for services we provide to
you.
: We may use and
disclose your health information in connection with our healthcare
operations. Healthcare operations include quality assessment and
improvement activities, reviewing the competence or qualifications
of healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
: In addition to our
use of your health information for treatment, payment or healthcare
operations, you may give us written authorization to use your health
information or to disclose it to anyone for any purpose. If you
give us written authorization, you may revoke it in writing at any
time. Your revocation will not effect any use or disclosures permitted
by your authorization while it was in effect. Unless you give us
a written authorization, we cannot use or disclose your health information
for any reason except those described in this Notice.
: We must
disclose your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health information
to a family member, friend or other person to the extent necessary
to help with your healthcare or with payment for your healthcare,
but only if you agree that we may do so.
: We may use
or disclose health information to notify, or assist in the notification
of (including identifying or locating) a family member, your personal
representative or another person responsible for your care, of your
location, your general condition, or health. If you are present,
then prior to use or disclosure of your health information, we will
provide you with an opportunity to object to such uses or disclosures.
In the event of your incapacity or emergency circumstances, we will
disclose health information based on a determination using our professional
judgment disclosing only health information that is directly relevant
to the person’s involvement in your healthcare. We will also
use our professional judgment and our experience with common practice
to make reasonable inferences in your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays,
or other similar forms of health information.
: We
will not use your health information for marketing communications
without your written authorization.
: We may use or disclose
your health information when we are required to do so by law.
: We may disclose your
health information to appropriate authorities if we reasonably believe
that you are a possible victim of abuse, neglect, or domestic violence
or the possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat to
your health or safety of the health or safety of others.
: We may disclose to
military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized federal
officials health information required for lawful intelligence, counterintelligence,
and other national security activities. We may disclose to correctional
institution or law enforcement officials having lawful custody of
protected health information of inmate or patient under certain
circumstances.
: We may use or
disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
___________________________________________
: You have the right to look at
or get copies of your health information, with limited exceptions.
You may request that we provide copies in the format other than
photocopies. We will use the format you request unless we cannot
predictably do so. (You must make a request in writing to obtain
access to your health information. You may obtain a form to request
access by using the contact information listed at the end of this
Notice. We will charge you a reasonable cost-based fee for expenses
such as copies and staff time. You may also request access by sending
us a letter to the address at the end of this Notice. If you request
copies, we will charge you $5.00 for each page, $25.00 per hour
staff time to locate and copy your health information, and postage
if you want the copies mailed to you. If you request an alternative
format, we will charge a cost-based fee fro providing your health
information in that format. If you prefer, we will prepare a summary
or an explanation of your health information for a fee. Contact
us using the information listed at the end of this Notice for a
full explanation of our fee structure.)
: You have the
right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other
than treatment, payment, healthcare operations and certain other
activities for the last 6 years, but not before April 14, 2003.
If you request this accounting more than once in 12 month period,
we may charge you a reasonable, cost-based fee for responding to
these additional requests.
: You have the right to request
that we place additional restrictions on our use or disclosure of
your health information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except
in an emergency).
: You have
the right to request that we communicate with you about your health
information by alternative means or to alternative locations. (You
must make your request in writing.) You request must specify the
alternative means or location, and provide satisfactory explanation
how payments will be handles under the alternative means or location
you request.
: You have the right to request
that we amend your health information. (Your request must be in
writing, and it must explain why the information should be amended.)
We may deny your request under certain circumstances.
: If you receive this
Notice on our Web site or by electronic mail (e-mail), you are entitled
to receive this Notice in written form.
___________________________________________
If you want more information about our privacy practices or have
questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights,
or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict
the use or disclosure of your health information or to have us communicate
with you by alternative means or at alternative locations, you may
complain to us using the contact information listed at the end of
this Notice. You may also submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with
the address to file your complaint with the U.S. Department of Health
and Human Services upon request.
We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
: Office Manager
: 312-432-1132
: dara@spa32.com
: 832 W. Adams Street
Chicago
, IL 60607 |
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