Sterling Rock Falls Clinic 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.

Sterling Rock Falls Clinic acts to maintain the privacy of protected health information and provide individuals with notice of Sterling Rock Falls Clinic's legal duties and privacy practices with respect to protected health information as described in this Notice and abide by the terms of the Notice currently in effect.

Provision of Notice:

Sterling Rock Falls Clinic provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided no later than the date of the first treatment to the patient after April 13, 2003.

Sterling Rock Falls Clinic makes its Notice available to any member of the public to enable prospective patients to evaluate Sterling Rock Falls Clinic's privacy practices when making his or her decision regarding whether to seek treatment from Sterling Rock Falls Clinic. Sterling Rock Falls Clinic provides its Notice via e-mail to any patient or other individual who so requests the Notice.

Documentation of Provision of Notice:

When a direct treatment patient receives the Notice from Sterling Rock Falls Clinic, Sterling Rock Falls Clinic asks the patient to sign its 'Receipt of Notice of Privacy Practices' form. The form is either filed with the patient's medical record or stored electronically in the Clinic's computerized practice management system. If the patient refuses to sign the form, it is noted in either place noted above that the patient was given the Notice and refused to sign the form.

Effective Date and Changes to Notice:

This Notice is effective April 14, 2003. Sterling Rock Falls Clinic reserves the right to revise this Notice. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is reflected.

If the Notice is revised, Sterling Rock Falls Clinic makes the revised Notice available upon request beginning on the revision's effective date. The revised notice is posted prominently in each of the Sterling Rock Falls Clinic's practice locations.

Complaints:

Sterling Rock Falls Clinic allows all patients and their agents to file complaints with Sterling Rock Falls Clinic and with the Secretary of the federal Department of Health and Human Services (DHHS). A patient or his or her agent may file a complaint with Sterling Rock Falls Clinic whenever he or she believes that Sterling Rock Falls Clinic has violated their rights.

Complaints to Sterling Rock Falls Clinic must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of Sterling Rock Falls Clinic's Privacy Officer at Sterling Rock Falls Clinic's address. Sterling Rock Falls Clinic investigates each complaint and may, at its' discretion, reply to the patient or the patient's agent.

Complaints to the Secretary of the Department of Health and Human Services must be in writing, must name Sterling Rock Falls Clinic, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation.

Sterling Rock Falls Clinic does not take any adverse action against any patient who files a complaint (either directly or through an agent) against the Sterling Rock Falls Clinic.

Contact Person:

Sterling Rock Falls Clinic has a privacy officer that serves as the contact person for all issues related to the Privacy Rule. If you have any questions about this Notice, please contact the Sterling Rock Falls Clinic, Attention Privacy Officer at (815) 625-4790 or at 101 E. Miller Road, Sterling, IL 61081.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Sterling Rock Falls Clinic treats all qualified individuals as personal representatives of patients. Sterling Rock Falls Clinic generally allows individuals to act as personal representatives of patients if legally authorized. The two general exceptions to allowing individuals to act as personal representatives relate to unemancipated minors and abuse, neglect, or endangerment situations.

Sterling Rock Falls Clinic makes reasonable efforts to ensure that protected health information is only used by and disclosed to individuals that have a right to the protected health information. Toward that end, that practice makes reasonable efforts to verify the identity of those using or receiving protected health information.

In Illinois, a specific written authorization is required to disclose or release of mental health treatment, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information.

Uses and Disclosures – Common Practices

The Sterling Rock Falls Clinic uses a number of common practices in the delivery of care to patients. These include such things as:

• Sharing of a common electronic medical record with CGH Medical Center and its' employed or contracted physicians and staff for treatment purposes;
• Use of email for the delivery of patient reminders or recall notices, messages about services offered, statements, or general communications to our patients;
• Leaving messages on answering machines; and
• Use of automated systems to deliver appointment reminders or to deliver test results.

Uses and Disclosures – Treatment, Payment, and Health Care Operations

Sterling Rock Falls Clinic uses and discloses protected health information for payment, treatment, and health care operations. Treatment includes those activities related to providing services to the patient, including releasing information to other health care providers involved in the patient's care such as hospitals where the physicians provide services. Payment relates to all activities associated with getting reimbursed for services provided, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. Health care operations includes a number of areas, including quality assurance and peer review activities.

Uses and Disclosures – Not Requiring Authorization

Disclosure to Those Involved in Individual's Care: Sterling Rock Falls Clinic discloses protected health information to those involved in a patient's care when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of Sterling Rock Falls Clinic.

When the patient is not present, Sterling Rock Falls Clinic determines whether the disclosure of the patient's protected health information is authorized by law and if so, discloses only the information directly relevant to the person's involvement with the patient's health care.

Sterling Rock Falls Clinic does not disclose protected health information to a suspected abuser, if, in its professional judgment, there is reason to believe that such a disclosure could cause the patient serious harm. Further, Sterling Rock Falls Clinic uses and discloses information as required by law.

Uses and Disclosures Required by Law:

Sterling Rock Falls Clinic uses and discloses protected health information to appropriate individuals as required by law.

As required by law Sterling Rock Falls Clinic discloses protected health information to public health officials. This includes reporting of communicable diseases and other conditions, sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated reports of injury, medical conditions or procedures, or food-borne illness including but not limited to adverse reactions to immunizations, cancer, adverse pregnancy outcomes, death and birth.

Sterling Rock Falls Clinic discloses protected health information regarding victims of abuse, neglect, or domestic violence. Sterling Rock Falls Clinic discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom Sterling Rock Falls Clinic reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse.

Sterling Rock Falls Clinic informs the individual of the reporting unless Sterling Rock Falls Clinic, in the exercise of professional judgment, believes informing the individual would place the individual at risk of serious harm or Sterling Rock Falls Clinic would be informing a personal representative, and Sterling Rock Falls Clinic believes the personal representative is responsible for the abuse, neglect, or other injury, and that informing such person would not be in the best interests of the individual as determined by the professional judgment of Sterling Rock Falls Clinic.

Uses and Disclosures for Health Oversight Activities:

Sterling Rock Falls Clinic uses and discloses PHI as required by law for health oversight activities. The information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but limited to hospital peer review, managed care peer review, or Medicaid or Medicare peer review.

Disclosures for Judicial and Administrative Proceedings:

In general, Sterling Rock Falls Clinic discloses information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal.

Disclosures for Law Enforcement Purposes:

Sterling Rock Falls Clinic discloses PHI for law enforcement purposes in the following situations:

As required by law; in compliance with a court order or court-ordered warrant, a summons or subpoena (if issued by a judicial officer or a grand jury), or an administrative request that meets certain requirements; If the information is limited to that necessary for identification and location purposes in response to a law enforcement official's request; Regarding the victim of a crime if the person agrees or, if the person is not able to agree, if the law enforcement official makes appropriate representations regarding the need for the information and Sterling Rock Falls Clinic personnel determine that the disclosure is in the individual's best interests; About a person who has died for purposes of alerting law enforcement officials about the death, if there is a suspicion that the death was the result of criminal conduct; If there has been a crime committed by the individual at Sterling Rock Falls Clinic; or To report crime in an emergency situation.

Uses and Disclosures Related to Decedents:

Sterling Rock Falls Clinic uses and discloses PHI as required to a coroner or medical examiner and funeral directors as required by law. The attending physician is required to sign the death certificate and provide the coroner with a copy of the decedent's protected health information.

Uses and Disclosures Related to Cadaveric Organ, Eye or Tissue Donations:

Sterling Rock Falls Clinic uses and discloses protected health information to facilitate organ, eye or tissue donations.

Uses and Disclosures to Avert a Serious Threat to Health or Safety:

Sterling Rock Falls Clinic uses and discloses protected health information to public health and other authorities as required by law to avert a serious threat to health or safety. The disclosure must be made to the person(s) reasonably able to prevent or lessen the threat, or, if disclosure is necessary to a law enforcement official, it must be made because of an admission of participation in a violent crime that may have caused serious harm to the victim, or it appears that the person has escaped from legal custody. Disclosures will be made only of the information necessary to avert the threat to health or safety.

Uses and Disclosures for Specialized Government Functions:

Sterling Rock Falls Clinic uses and discloses protected health information for military and veterans activities, national security and intelligence activities, and other activities as required by law.

Uses and Disclosures in Emergency Situations:

Sterling Rock Falls Clinic uses and discloses protected health information as appropriate to provide treatment in emergency situations. In those instances where Sterling Rock Falls Clinic has not previously provided its Notice of Privacy Practices to a patient who receives direct treatment in an emergency situation, Sterling Rock Falls Clinic provides the Notice to the individual as soon as practicable following the provision of the emergency treatment.

Research:

Sterling Rock Falls Clinic occasionally participates in research activities and will work with the researcher to determine the appropriate authorization.

Other Uses and Disclosures:

Sterling Rock Falls Clinic will obtain an authorization for any other uses or disclosures not described in this notice.

INDIVIDUAL RIGHTS

Individual Rights – Accounting for Disclosures of Protected Health Information

Sterling Rock Falls Clinic tracks all disclosures of a patient's protected health information that occur for other than the purposes of treatment, payment, and health care operations, that are not made to the individual or to a person involved in the patient's care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials.

Sterling Rock Falls Clinic allows an individual to request one accounting within a 12-month period free of charge. Sterling Rock Falls Clinic charges a reasonable fee for more frequent accounting requests. An individual can request an accounting of disclosures for a period of up to six years prior to the date of the request. Requests for shorter accounting periods will be accepted. However, patients may only request an accounting of disclosures made on or after April 14, 2003.

Sterling Rock Falls Clinic responds to all requests for an accounting of disclosures within 60 days of receipt of the request. If Sterling Rock Falls Clinic intends to provide the accounting for disclosures and cannot do so within 60 days, Sterling Rock Falls Clinic informs the requestor of such and provides a reason for the delay and the date the request is expected to be fulfilled. Only one 30-day extension is permitted.

A request for an accounting for disclosures must be made in writing and mailed or sent to Sterling Rock Falls Clinic. It should be marked 'Attention: Privacy Officer.'

Individual Rights – Inspect and Copy Protected Health Information

Sterling Rock Falls Clinic allows individuals to inspect and copy their protected health information, documents all requests, responds to those requests in a timely fashion, informs individuals of their appeal rights when a request is rejected in whole or in part, and charges a reasonable fee for the copying of records.

Sterling Rock Falls Clinic reviews the request in a timely fashion and acts on a request for access generally within 30 days. Sterling Rock Falls Clinic may have a single extension of 30 days, if needed to act on the request. Each request will be accepted or denied and the requestor notified in writing. If a request is denied, the requestor is informed if the denial is 'reviewable' or not. The requestor has the right to have any denial reviewed by a licensed health care professional who is designated by Sterling Rock Falls Clinic as a reviewing official and who did not participate in the original decision to deny. Sterling Rock Falls Clinic informs the requestor of the decision of the reviewing official and adheres to the decision.

Sterling Rock Falls Clinic charges reasonable fees based on actual cost of fulfilling the request. Sterling Rock Falls Clinic will determine the appropriate charge for providing the requested records and inform the requestor in advance of providing the records. If the requestor agrees to pay the fee in advance, the records will be provided. Otherwise, the records will not be provided, unless the Privacy Officer determines that the charge is burdensome to the requestor.

Illinois law prohibits charges that exceed the following: 75 cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for pages 51 to end; plus actual expenses related to the copying of x-rays, CAT scans, and similar. Sterling Rock Falls Clinic limits charges for records to the amounts allowed under Illinois law.

Requests for the inspection and copying of records must be sent to Sterling Rock Falls Clinic in writing. It should be marked 'Attention: Privacy Officer.'

Individual Rights – Request Amendment to Protected Health Information

Sterling Rock Falls Clinic allows an individual to request that Sterling Rock Falls Clinic amend the protected health information maintained in the patient's medical record or the patient's billing record. The Sterling Rock Falls Clinic may request that these requests be made in writing if the Clinic believes it is necessary to do so. Sterling Rock Falls Clinic documents requests, responds to those requests in a timely fashion, and informs individuals of their appeal rights when a request is denied in whole or in part.

Generally, Sterling Rock Falls Clinic will act on a request for amendment no later than 60 days after receipt of such a request. If Sterling Rock Falls Clinic cannot act on the amendment within 60 days, Sterling Rock Falls Clinic extends the time for such action by 30 days and, within the 60-day time limit, provides the requestor with a written statement of the reasons for the delay and the date by which Sterling Rock Falls Clinic will complete action on the request. Only one such extension is allowed.

If Sterling Rock Falls Clinic denies the request, in whole or in part, Sterling Rock Falls Clinic provides the requestor with a written denial in a timely fashion. Sterling Rock Falls Clinic allows a requestor to submit a written statement disagreeing with the denial of all or part of the initial request. The statement must include the basis of the disagreement. Sterling Rock Falls Clinic limits the length of a statement of disagreement to one page.

Sterling Rock Falls Clinic accepts requests to amend the PHI maintained by Sterling Rock Falls Clinic. The requests must be in writing and should be marked 'Attention: Privacy Officer.'

Individual Rights – Request Confidential Communications

Sterling Rock Falls Clinic accommodates all reasonable requests to keep communications confidential. Sterling Rock Falls Clinic determines the reasonableness based on the administrative difficulty of complying with the request.

A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to Sterling Rock Falls Clinic's Privacy Officer. No reason for the request needs to be stated.

Sterling Rock Falls Clinic accommodates all reasonable requests. Sterling Rock Falls Clinic may reject a request if no independently verifiable method of communication such as a mailing address or published telephone number is provided for communications, including billing; or if the requestor has not provided information as to how payment will be handled.

Sterling Rock Falls Clinic will not refuse a request: if the requestor indicates that the communication will cause endangerment; or based on any perception of the merits of the requestor's request.

Individual Rights – Request Restriction of Disclosures

Sterling Rock Falls Clinic patients may request restrictions of disclosures of protected health information. Sterling Rock Falls Clinic is not obligated to agree.

All requests for restrictions of disclosures must be submitted in writing. They must be sent to the attention of the Sterling Rock Falls Clinic's Privacy Officer. The Privacy Officer notifies the requestor in writing whether the Sterling Rock Falls Clinic will accept the restriction.

Individual Rights – Waiver of Rights

Sterling Rock Falls Clinic never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law.