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.
Our Duties:
We are required by law to maintain
the privacy of your medical information and to provide you
with notice of our legal duties and privacy practices. We
are required to abide by the terms of the Notice of Privacy
Practices currently in effect. We reserve the right to change
those terms and any changes made will be effective for all
medical information we maintain. A copy of the revised notice
will be available at any of our offices by contacting the
Priivacy Officer or by calling (815) 633.3050 or by writing
to Galluzzo Foot and Ankle Clinic, 3427 No. Rockton Ave. Rockford,
IL 61103. You may also address questions regarding our privacy
practices, your privacy rights, or requests for additional
information regarding your privacy to this person.
Permitted Uses and Disclosures:
Federal Law allows use and disclose
your medical information in the ordinary course of providing
healthcare services to you. We have described some of these
uses and disclosures in the following paragraphs:
• Treatment: We will provide to your
other healthcare providers the minimal information they need
to treat you. We may contact you before an appointment or
talk to you about preparing for an appointment or a procedure.
We will try to contact you at the phone numbers you have given
us. If you are not available and your voice mail answers,
we may leave a brief message to remind you of the place and
time of your appointment . We may ask you to call us regarding
specific medical information concerning your case. We will
not leave your test results or your diagnosis on your voice
mail machine.
• Payment: We will bill your insurance
company and you directly or another person who may be responsible
for payment of your account. We may need to contact you health
plan to pre-authorize the exams, procedures or tests your
doctor has ordered. Throughout this process we may have to
release details of your medical information, if your health
plan or other payer requires this information to make payment.
If you do not want this information released to your payer,
then you must pay your bill in full at the time of service
and inform us not to bill anyone else.
• Health Care Operations: We often have
to use specific patient information to conduct our normal
business operations. We may have to look at the information
in the doctor’s reports in order that we may fill out forms
on your behalf. We may have to compare x-rays taken from other
facilities with those in our file. We may use PHI to review
our treatment and services and to evaluate the performance
of our staff in caring for you.
Disclosures without Authorization
We may use and disclose medical
information about you, without your specific authorization,
as follows:
• Disclosures Required by Law: We may
be required by federal, state, or local law to disclose your
medical information.
• Public Health Activities: We may disclose
your medical information to a public agency, such as the Food
and Drug Administration (FDA), if you experience an adverse
effect from any of the drugs, supplies, or equipment we use.
• Victims of Abuse, Neglect, or Domestic
Violence: We may be required to disclose your medical
information if we feel that you have been abused or neglected.
• Judicial and Administrative Proceedings:
We may have to disclose your medical information if we receive
a subpoena from a judge or administrative tribunal.
• Law Enforcement: We may have to disclose
your medical information in conjunction with a criminal investigation
by a federal or state law enforcement agency.
• Serious Threats to Health or Safety:
We may be required to disclose your medical information if,
in our opinion, doing so will help avert a serious threat
to the public.
• Military Personnel: We may disclose
your medical information to the appropriate command authorities.
• Worker’s Compensation: We may disclose
your medical information to comply with laws regarding worker’s
compensation.
Patient Rights
You have certain rights with respect
to your medical information. While Federal law allows us to
use and disclose your PHI for treatment, payment and health
care operations, the law requires us to obtain your written
consent to do so. Therefore, the first time you see one of
our Physicians or health care providers, we will ask you to
sign a consent form allowing us to use and disclose you personal
information in conjunction with your treatment, payment for
treatment and our healthcare operations.
Requesting Restrictions: You may ask
us to limit our use or disclosure of your protected health
information. We are not required to agree to your request,
but if we agree to it, we will abide by your request except
as required by law, in emergencies, or when the information
is necessary to treat you. Your request must: 1) be in writing,
2) describe the information that you want restricted, 3) state
if the restriction is to limit our use or disclosure, and
4) state to whom the restriction applies. You may revoke your
restriction at any time by contacting our Privacy Officer
as noted on the first page. We may ask to reschedule your
exam while we consider your request.
Confidential Communications: You may
ask that we communicate with you in a particular way, or at
a certain location to maintain your confidentiality. Your
request must be in writing. It must tell us how you intend
to satisfy your financial responsibility, and specify an alternate
way that we can contact you confidentially. You do not have
to give a reason for your request. You may revoke your request
at any time by contacting our Privacy. We may ask to reschedule
your exam while we consider your request.
Inspect and Copy: You may request access
to inspect and copy your medical information maintained in
our records, including billing records. Your request must
be in writing. We will act on your request for inspections
within 5 working days after we get the request. We will act
on your request for copies within 15 days after we get the
request. If we must deny your request, we will send you a
written denial. If this happens, you may request a review
of the denial. We hire an independent copy company to copy
records for us. That company will send you a bill for the
copies. If you want to know the charges in advance, you may
request it. The copy service charges are based on state guidelines.
If you have a dispute over the bill for copying you will need
to dispute it with the copy service. The copies may be picked
up in one of our offices at your request, or they may be mailed
to you.
Amendment: You may ask us to amend your
health information if you believe that it is incorrect or
incomplete. Your request must be in writing and must include
a reason to support the amendment. Your request may be denied
if we believe that the information is complete and accurate,
if the information is not part of the medical information
that you would be permitted to inspect or copy, or if we did
not create the information. You also have the option of submitting
your own amendment. This amendment must be in writing and
cannot be longer than 250 words per item that you are trying
to correct. We will then include this amendment when we release
the records in question.
Accounting of Disclosures: You may request
a list of non-routine disclosures that we have made of your
medical information. This does not include disclosures we
make for your treatment, to seek payment for our services,
or for our normal business operations or for those you authorize
in writing. You may request an accounting for dates of service
not prior to April 14, 2003. Your first request within a 12-month
period is free, but we may charge for additional lists within
the same 12-month period.
File a Complaint: If you believe that
we have violated your privacy rights, you may file a complaint
directly with our Privacy Officer using the contact information.
You may also file a complaint with the Secretary of the Department
of Health and Human Services. We will not penalize you for
complaining.
Patient Authorizations for Certain Disclosures
We will request your written authorization
for uses and disclosures of your medical information that
we did not identify in this notice or for those not otherwise
permitted by law. These disclosures may include your requests
to provide exam results to your attorney, for exams related
to life insurance or disability insurance applications or
for pre-employment physicals. You may revoke your authorization
in writing at any time by contacting our Privacy Officer.
You may request a copy of your authorization at any time.
