Notice of Privacy Practices for Patients of Illinois Sports Medicine and Orthopaedic Center (ISMOC)

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 covers all information in our written or electronic records which concerns you, your health care and payment for your health care. It also covers information we may have shared with other organizations to help us provide your care, get paid for providing care or manage some of our administrative operations. By federal law (the Health Insurance Portability and Accountability Act–HIPAA) we must now provide this notice to you.

Our patients will be asked to sign a consent form to enable us to provide them with proper medical treatment. We are required by HIPAA to maintain the privacy of information we gather and use about our patients, and provide them with notice of our legal duties and privacy practices with respect to their information.

How We May Use or Disclose Your Protected Health Information

Without your consent or authorization, we may disclose information about you only for the following purposes:

  • To a public health agency, for purposes such as controlling disease.
  • In cases of suspected child abuse, to the appropriate governmental authority.

  • In other cases of suspected abuse, neglect or domestic violence, to the appropriate governmental authority, 1) with your agreement, 2) if required by law, 3) if you are incapacitated, 4) or it appears necessary to prevent serious harm to you or others.
  • To health oversight authorities, for regulatory, licensing and other legal purposes.
  • In litigation, subject to certain requirements controlling the terms of disclosure.
  • To law enforcement agencies, subject to applicable legal requirements and limitations.
  • For medical research purposes, subject to your authorization or approval or approval by an institutional review board.
  • If you are in the US military, national security or intelligence, or foreign service, to your authorized superiors or other authorized federal officials.

With your written consent we can use or disclose your information for the following purposes:

  • Treatment: We may use or disclose information about you for treatment purposes to doctors, nurses, technicians, medical students or other individuals who work in our practice who are involved in providing you with health care. We may also disclose information about you to organizations and individuals in your care who are outside of our practice, such as consulting physicians, laboratories, nurse case managers for workers’ compensation claims, and so on.
  • Payment: We may use or disclose information about you for payment purposes to our billing department. We may also disclose such information to your health plan or other party financially responsible for your care, or to claims and billing services, if necessary.
  • Health care operations: We may use or disclose information about you for operational purposes in connection with our practice. These activities might include quality improvement of our practice, training of medical students, insurance underwriting, medical or legal review, business planning or administration of our practice, follow-up of the efficacy of patient treatment. Other examples of how ISMOC may use your protected health information include communicating appointment reminders, sending you information to support your health care, a directory/sign-in log of patients seeking treatment in our office, disclosures to family and friends or other person that you designate is involved in your care or payment for your care, and use and disclosure of health information that may be related to your care but does not identify you and can’t be used to identify you (e.g. medical research).

Please inform us if you do not wish to receive medical communications from us at the address listed below.

We may not use or disclose information about you for any other purpose without your written authorization, provided separately from your written consent.

Your Legal Rights in Connection with Your Health Care Information

By law you are entitled to:

  • Ask us to further restrict our use and disclosure of information about you. We are not required to grant such a request, but if we do, we must make sure the restrictions are implemented.
  • Receive confidential communications from us, at an alternative address you provide to us.
  • Review our records for your information. We may charge a fee for the cost of copying, mailing or related supplies.
  • Ask us to amend your records, if you believe that they are incorrect or incomplete. We are not required to make such an amendment. If you request an amendment and we determine we will not make it, you are entitled to have a statement of your disagreement included in your records. If you include a statement of disagreement in your records, we may include a statement of explanation or response in your records as well.
  • Obtain an accounting of all persons to which we have disclosed information about you, for any purpose except your treatment, payment for your treatment, or our health care operations. You must submit a written request stating the time period desired for the accounting, which must be less than a six-month period and starting after April 14, 2003. The first disclosure list in a 12-month period is free. A fee to cover costs will be applied to subsequent requests for disclosure within the 12-month period.
  • If you have provided us with an authorization for any purpose, you may revoke it at any time. You may revoke an authorization by giving us written notice at our contact address given below. Your revocation will be effective as of the time we receive it, and will not apply to any uses or disclosures that occur before that time. Revocation of consent for treatment, payment or health care operations will most likely result in our inability to provide you with health care.
  • If you believe we have violated your privacy rights, you may forward a written complaint to our contact address given below. You may also file a complaint with the Secretary of the United States Department of Health and Human Services at: Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601. Voice phone: (312) 886-2359, Fax: (312) 886-1807, TDD: (312) 353-5693. If you do file a complaint, we are legally prohibited from retaliating against you.

This notice is published by Illinois Sports Medicine and Orthopaedic Center (ISMOC). It applies to everyone who works for ISMOC, including our employees, contractors, and volunteers.

This notice is effective as of April 14, 2003, and will remain in effect until the date we publish an amended notice. If we do publish an amended notice, we will make copies of that notice available in our office and on our website: www.ISMOC.net

If you have any questions about this notice, please contact Illinois Sports Medicine and Orthopaedic Center at 1714 Milwaukee Ave., Glenview, IL 60025.

Our privacy officer is Chadwick Prodromos, MD, Medical Director of Illinois Sports Medicine and Orthopaedic Centers. Phone: Email: [javascript protected email address]

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