NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact our privacy officer:
Denise Black, Orthopedic Rehab Specialists
2662 McFarland Road Rockford, IL 61107
815-227-1700

This notice describes the procedures and practices that this clinic and its professional, support and administrative staff follow to protect the privacy of your health information.

What is Covered by this Notice?

This Notice describes the way your health information may be used and disclosed by us, and describes your rights and our obligations concerning your protected health information.

This notice covers the health care services provided at our affiliated covered entities herein referred to as “Clinic”: Orthopedic Rehab Specialists currently located at 2662 McFarland Road in Rockford, Illinois, 5306 Williams Drive in Roscoe, IL as well at 209 N. Union Street in Byron, Illinois, Certified Hand Center of Rockford currently located at 2662 McFarland Road in Rockford Illinois as well at 209 N. Union Street in Byron, Illinois, Belvidere Rehab & Sports Medicine located at 1255 Logan Avenue in Belvidere, Illinois and Orthopedic Rehab Specialists of Dixon located at 20I Lincoln Statue Drive, Suite 102 in Dixon, Illinois.

How we may use and disclose your health information:

For treatment, payment, and health care operations:The Clinic and your health care providers may use or disclose your health information in order to provide you treatment,to obtain payment for such treatment, and for health care operations, which are activities related to the provision of health care.

For example, we may use or disclosure your health information for treatment purposes in order to provide, coordinate, or manage health care and related services among your health care providers, such as when one physician refers you to another health care provider or requests a consultation by a specialist.

We may use or disclose your health information for payment purposes, such as to bill your insurance company or Medicare in order to obtain reimbursement for the health care services provided you.

We may use or disclose your health information for health care operations purposes, such as for improving quality of care, reducing health care costs, conducting training programs for students or practitioners, and other activities such as for provider licensing or credentialing activities.

In addition, we may contact you to provide appointment reminders, to inform you about treatment alternatives or other benefits or services that may be of interest to you.

We may also use and disclose limited information about you, and may contact you, in connection with certain marketing activities on behalf of the Clinic.

Patient Listing: In the event you seek treatment at one of our clinics, your name, location and your general condition will be maintained in our electronic general patient listing.

In addition, with respect to your friends, family, relatives, and others whom you identify, we will not disclose certain information related to you, unless you give us permission to do so. If you are incapacitated or involved in an emergency, we may disclose such information without further opportunity for you to object.

We may disclose health information concerning your location and condition in attempt to notify or locate your family, personal representative, or other person responsible for your care, or to assist disaster relief authorities in such notification activities, again, unless you have objected, or without further opportunity to object if the situation involves emergency or incapacitation.

Finally, we will exercise professional judgment documenting what we did and taking the necessary precautions in an emergency situation and/or when allowing persons to act on your behalf in situations such as picking up your medical supplies, x-rays, or other forms of health information.

Additional disclosures made pursuant to law or for public policy purposes:There are a number of other situations in which we may use or disclose certain health information about you without requesting your authorization to do so, such as for public health activities or where the law authorizes such uses and disclosures. Such disclosures may involve reporting obligations (such as for victims of abuse), health oversight activities (such as for audits, inspections, or compliance activities), judicial or administrative proceedings (such as when called for by court order or subpoena), law enforcement purposes (such as for mandatory reporting of child abuse or in response to law enforcement inquiries about suspects or criminal conduct), coroners or funeral directors, certain research activities involving institutional review board waiver of authorization approval, disclosures necessary to avert serious threats to health or safety, certain government functions (such as relating to the military or national security) or workers’ compensation disclosures as authorized by State law.

We will abide with laws requiring disclosure of information. If a certain use or disclosure is addressed by more than one law, we will abide by the more stringent law.

Additional disclosures will be made only with your written Authorization:

In situations involving a use or disclosure of your health information which is not mentioned above, we will obtain written Authorization from you.

If you sign such an Authorization, you have the ability to later revoke it in writing, with certain exceptions such as if and to the extent that we have already relied on the original Authorization. For questions regarding the procedure for revoking an Authorization, you should contact our Privacy Official.

Your Rights With Respect to Your Own Health Information:

Under the law, you have the right to ask that we restrict certain types of uses and disclosures of your health information described above, specifically, those involving treatment, payment or health care operations and disclosures made to family, friends, or for notification purposes. Although we are not obligated to agree to requested restrictions, we will abide by restrictions which we have agreed to, unless necessary to provide you emergency treatment. To make such a request you may contact our Privacy Official or staff to obtain a REQUEST FOR RESTRICTION OF USES AND DISCLOSURES form. Depending on the request, it may be necessary to charge you a fee up to $40 for the costs associated with your request.

You have the right to ask that we communicate with you in a confidential nature, such as by contacting you through a certain telephone number or sending you information to a specific address. Such requests must be reasonable and must be made in writing, and may be made by contacting our Privacy Official or staff to obtain a REQUEST FOR CONFIDENTIAL COMMUNICATIONS form.

You have the right to request access to inspect and obtain a copy of your medical records, billing records, and other health information used to make decisions concerning you. Such requests must be in writing, and may be made by contacting our Privacy Official or staff to obtain an AUTHORIZATION form. We may charge you a fee up to $40 for supplying copies of the requested information. There is no charge for inspecting your medical records. In addition, there are situations in which we may need to deny your request. In the event of such a denial, we will notify you of the reasons, and advise you of further steps you may take concerning further review or complaint.

You have the right to ask that we amend health information we maintain about you if you believe such records are not accurate or complete. Such requests must be made in writing, and may be made by contacting our Privacy Official or staff to obtain a PATIENT REQUEST FOR AMENDMENT OF HEALTH INFORMATION form. If we accept your request, we will append and link such additional or clarifying information to your records. In the event we do not accept your request, we will notify you of the reasons, and advise you of further steps you may take concerning any disputed information or further disagreement you may have.

You have the right to receive an accounting, or listing, of certain types of disclosures of your protected health information made by us and by any business associates we have asked to perform a function on our behalf. However, this right and accounting does not include most routine types of disclosures that are made for health care purposes, such as disclosures made for treatment, payment, or health care operations, disclosures made to you, disclosures that you have authorized, disclosures made to family, friends and persons involved in your care, disclosures made for national security or intelligence, disclosures made to correctional institutions or law enforcement custodial situations, or disclosures that were made prior to 4/14/03. All requests for an accounting of disclosures must be made in writing, and may be made by contacting our Privacy Official or staff to obtain a PATIENT REQUEST FOR ACCOUNTING OF DISCLOSURES form. You may request an accounting for up to the 6 year period prior to your request, and we may charge you a fee up to $40 per request for more than one request in any twelve month period.

You have the right to request and obtain a paper copy of our current Notice of Privacy Practices.

Our Obligations to You:

We are required by law to maintain the privacy of your protected health information, to provide you with this Notice explaining our legal duties and our privacy practices with respect to your health information, and to follow the terms of the Notice of Privacy Practices currently in effect.

We may change the terms of our Notice of Privacy Practices, and such changes will apply to all protected health information maintained, including information which was created or received prior to the date of such revised Notice.

In the event we materially change the terms of our Notice of Privacy Practices, we will post any revised Notice at our office location and on any future website that we may maintain. You may obtain a copy of any revised Notice through the office of our Privacy Official.

Concerns or Complaints:

We are committed to upholding your privacy rights. If you at any time become concerned that your privacy rights may have been violated or otherwise disagree with a decision concerning access to or handling of your health information, we ask that you provide us an opportunity to address your concerns by contacting the office of our Privacy Official at (815) 489-3954 or (815) 227-1700. You may be asked to file your concerns in writing to the attention of our Privacy Official at Orthopedic Rehab Specialists, 2662 McFarland Road, Rockford, IL 61107.

You may also send a written complaint to the Secretary, Department of Health and Human Services if you believe that your privacy rights have been violated.

You will not be penalized or retaliated against for making such inquiries or complaints.

Contact Person for Further Information:

Should you have any questions or would like further information concerning matters contained in our Notice of Privacy Practices, please contact the office of our Privacy Official at (815) 489-3954 or (815) 227-1700.

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