Ingalls Same Day Surgery

Privacy Notice

This Notice applies to all the health records that we maintain for you. We are required by law to maintain the confidentiality of your health information and to give you this Notice describing our practices and legal duties and your rights regarding your health information. We must follow the terms of the Notice that is in effect. The effective date of our Notice can be found in the upper right hand corner.

The practices described in this Notice apply to all our employees, volunteers, students-in-training, contract staff, all members of our medical staff and their employees who may perform tasks at any of our locations and any other person authorized to make entries into or obtain information from your medical record. We refer to Ingalls Same Day Surgery as (“ISD”) in the rest of this document.

We Will Use and Disclose Information About You to Provide Treatment, Obtain Payment for Services, and to Meet Operational Needs.

When you seek medical treatment at ISD, your information will be used within ISD and disclosed outside of ISD for the purposes described below:

Treatment: To provide you with health care services. Information gathered by a nurse, doctor or other member of your treatment team will be entered into your record and used to determine your course of treatment and your response to treatment. This information may also be shared with other parties involved in your care including consulting health care providers, other facilities to which you may be transferred, and other health care providers treating you.

Payment: To obtain payment for the services we have provided to you. We will use your information to verify that you have insurance coverage. A bill, which identifies you and contains your diagnosis and the procedures performed will be sent to your insurer or to you or to some other third party identified as a payer. We may disclose billing information to other health care providers involved in your care so that they have correct billing information. If you are overdue in paying your bill, information about you may be shared with collections agencies.

Health Care Operations: To meet the operational needs of ISD. For example, we will use your health information to review the skills of our health care professionals, to conduct training or education programs, and to perform quality reviews of our treatment protocols. Your health information may be disclosed to students who observe treatment and other procedures during supervised programs within our facility such as the Health Science Institute. Your health information may be disclosed to other providers involved in your care for their own health care operations.

Contacting you: To contact you about your appointments or other matters. We may contact you by telephone, mail or e- mail. We may leave voice messages at the number you have provided us.

Health Care Coordination, Related Services and Products: To coordinate your care and to advise you of alternative therapies, settings of care, or providers. We may use or disclose your information so that someone may contact you about services available. We may tell you about another company’s products or services in face-to-face communications.

Business Associates: We may disclose your health information to certain third parties known as Business Associates who contract with us to perform certain services on our behalf. These third parties are obligated within their contract to take certain steps to protect your health information.

Limited Data Sets and De-Identified Information: We may disclose certain parts of your information as a ‘limited data set’ for use in research, certain public health purposes or for our operational needs. Information that does not identify you in any way is considered to be ‘deidentified’
and can be used or disclosed for any purpose.

THIS NOTICE DISDRIBES HOW MEDICAL INFORMATION ABOUT YOU WILL BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. Sharing Information With Your Family, Relatives, Close Friends and Others Involved in Your Care or Payment for Your Care.

If you agree verbally or do not voice an objection we will use your information in the following circumstances:

Facility Directory: Unless you object, we may include your name and location in the facility in a facility directory. I f anyone asks for you by name, we will give them your room and telephone number, when applicable, and briefly describe your condition. If you do not wish others to know that you are here, please let the registration desk know as soon as possible on your admission.

Emergency Notification: If you are treated in an emergency situation and do not object, we may notify members of your family or other persons you identify that you are here. In the event of a disaster, we may notify the Red Cross or other agencies responsible for family notification of your presence in the facility.

Communication With Family: Unless you object, we may discuss your health care with members of your family, close friends or other individuals you identify who may be involved in your care or the payment for your care.

When It Is Reasonable to Assume That You Do Not Object: If you request that a family member or friend be present during an examination or discussion or you do not request the family member or friend to leave, we will assume that you do not object to information about you being discussed in the presence of that person. If you are unable to tell us whether you agree or object to a disclosure for any of the reasons listed in this section, we may discuss your treatment or your bill with your family, relative, close friend or other persons involved in your care or payment for your care. In these cases, we would share only what is important for them to know i f, based on our professional judgment, we decide that it is in your best interests for information to be shared.

Uses or Disclosures for Research or When Authorized by Law

We may use or disclose your health information without your permission in the following circumstances, subject to all applicable legal requirements and limitations.

Research: To organizations that participate, for research activities under certain limited circumstances which are subject to a special approval process.

As Required By Law: When required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety: To prevent a serious threat to your health and safety or the health and safety of the public or another person.

Organ and Tissue Donation: To organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military: If required by the appropriate military command authority. Worker’s Compensation and Medical Surveillance: To your employer, case manager, other health care providers and workers comp insurer as permitted or required by state law.

Public Health Activities: As authorized by law to local, state or federal public health authorities for various public health activities including: recording births and deaths; reporting certain illnesses, injuries or communicable diseases; reporting unanticipated medication reactions,
problems with medical devices or other unanticipated problems with your care; notifying you that you may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Child and Adult Abuse, Neglect or Endangerment: To report known or suspected child or adult abuse, neglect or endangerment to the appropriate law enforcement authorities.

Health Oversight Activities: To health oversight agencies who monitor our compliance with the law. In addition, individual employees, volunteers, trainers or contractors may use or disclose information about you in a ‘whistleblower’ action.

Legal disputes: In response to a court or administrative order or other court proceeding that compels release of the information.

Law Enforcement: To local, state or federal law enforcement officials when required by law, to identify or locate persons in our facilities, to report known or suspected criminal activity or when necessary to provide for national or state security.

Coroners, Medical Examiners and Funeral Directors: To a coroner or medical examiner or funeral director as authorized by law.

Other Uses and Disclosures of Health Information

Records of Mental Health and Alcohol or Substance Abuse Patients: If you are receiving mental health, alcohol or substance abuse treatment, your records may be subject to additional protections under federal and state law. Please contact the facility Privacy Officer or Medical Records Coordinator with any questions you may have using the address or telephone number provided below.

Incidental Uses and Disclosures: Although we take reasonable safeguards to avoid this, your information may be unintentionally used or disclosed to others when such action is ‘incidental’ to a use or disclosure that is otherwise permitted by the law. For example, a conversation about you
between your caregivers may be overheard.

Uses and Disclosures Not Covered By This Notice: Uses and disclosures not covered by this notice or the laws that apply to us will be made only with your written permission. You may, in most cases, revoke that permission, in writing, at any time. Note that we are unable to recover information that was previously disclosed with your permission, and that we are required to retain our records of the care that we provided to you. We cannot accept a revocation of your written authorization when it was given as a condition of obtaining insurance coverage since other laws give the insurer the right to contest a claim under the insurance policy. If you refuse to sign an authorization for release of information, we may not refuse to treat you unless 1.) the authorization is required as a condition of participation in a research related protocol, or 2.) the only reason for the health care encounter is to create health information for release to a third party (ex. A pre-employment physical or OSHA mandated testing for your employer.)

Your Rights Regarding Your Health Information

Right to Inspect and Copy: With some exceptions, you have the right to inspect and obtain a copy (for a fee when applicable) of the information we maintain on you in your medical records, billing records and other records used to make decisions about your care. We may deny your request to inspect and copy your information in certain limited circumstances. You may request review of a denial.

Right to Amend Information: If you believe that the health information we have about you is incorrect or incomplete, you may request that we amend the information. You have the right to request an amendment for as long as we keep your information. You must provide a reason for your request. We will deny your request 1.) if you do not provide a reason, or 2.) if the information was not created or maintained by us, or 3.) if the information is not within the records you are permitted to inspect and copy, or 4) if the information is accurate and complete.

Right to a List of Certain Disclosures: We are required to keep a list of certain (but not all) of the disclosures we make of your health information and you are entitled to a copy of that list. You must state the time period for which you want the list of disclosures, but the time period cannot be longer than the preceding six years, and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. However, if you request additional lists during this period, we will charge you for the costs of providing the list.

Right to Request Restrictions: You have the right to request that we limit the use or disclosures of your health information for treatment, payment or health care operations, but we do not have to agree. You also may request that we limit the information about you that we release to your family, close friends or others involved in your care or payment for care but, again, we do not have to agree. We will not accept restriction when release of information is required by law or when we lack the technical means to enforce a restriction. We cannot restrict information disclosed prior to your request for restriction. If we do accept your request, we will comply unless the information is needed to provide you emergency treatment. If we later decide to reverse a decision to accept your restriction, you will be notified in writing.

Right to Request Alternative Delivery of Information: You have the right to request that we communicate with you about health matters via alternative means or at alternative locations. For example, you may request that we only telephone you at work or that we mail your records to you at a location other than your home. Any request for alternative delivery of information must specify how or where you wish to be contacted. We will accommodate requests that we can reasonably meet.

Right to a Paper Copy of this Notice: You may obtain a paper copy of this Notice from the Receptionist desk and/or Admitting Desk at ISD. You may also print a copy from our website at www.ingallssameday.com.

IN ORDER TO EXERCISE THE RIGHTS DISDRIBED ABOVE, YOU MUST PROVIDE A WRITTEN REQUEST TO: Ingalls Same Day Surgery, Medical Records Department, 6701 West 159th St., Tinley Park, IL 60477

Questions about your rights may be directed to the Ingalls Same Day Surgery Privacy Officer at (708) 429-0222.

Changes to This Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in each facility. The Notice will
contain on the first page, in the top right-hand corner, the effective date of the Notice.