NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFRMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
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 (04/14/03), 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 'I, :' 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and
healthcare operations. For example:
Treatment:
We may use or disclose your health information to a physician or other
healthcare provider providing treatment to you.
Payment:
We may use and disclose your health information to obtain payment for services
we provide to you.
Healthcare 0perations:
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.
Your Authorization:
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 an
authorization, you may revoke it in writing at any time. Your revocation will
not affect any use or disclosure 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.
To Your Family and Friends:
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.
Persons, Involved in Care:
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 death. If you am 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 wi11 also use our professional judgment and our experience with
common practice to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of health information.
Marketing Health Related Services:
We will not use your health information for marketing communications without
your written authorization.
Required by Law:
We may use or disclose your health information when we are required to do so by
law.
Abuse or Neglect:
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 or the health or safety of others.
National Security:
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 official having lawful custody of
protected health information of inmate or patient under certain circumstances.
Appointment Reminders:
We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access:
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 a format other
than photocopies. We will use the format you request unless we cannot
practically 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 radiographs, we will charge you $20.00 to duplicate
them. If you request an alternative format, we will charge a cost-based fee for
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.)
Disclosure Accounting:
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 a 12 month period, we may charge you a reasonable, cost-based
fee for responding to these additional requests.
Restriction:
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).
Alternative Communication:
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.} Your request must specify the alternative means or
location, and provide satisfactory explanation how payments will be handled
under the alternative means or location you request.
Amendment:
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.
Electronic Notice:
If you receive this Notice on our Website or by electronic mail (e-mail), you
are entitled to receive this Notification in written form.
QUESTIONS AND COMPLAINTS
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 also may submit a written
complaint to the Department of Health and Human Services. We will provide you
with the address to file your complaint with till 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.
Contact Officer:
Telephone: (708)-361-2288
Fax: (708)-361-8522
E-mail:
complaints@drpatrickgannon.com
Address: 7480 W. College Drive Suite 202 Palos Heights, IL 60463