Notice of Health Information Practices
This notice describes how information about you may be used and
disclosed, and, how you can access this information. Please review
it carefully. We will also be obtaining your written acknowledgement
that you had the opportunity to review this notice. The CDHealth
entities included in this notice are Central DuPage Hospital,
Centra Corporation, HealthLab, Midwest Pathology Service , Midwest
Pathology Consultants PC, Central DuPage Special Health Association
(CNS Pharmacy), Community Nursing Service of DuPage County, and
Wynscape Nursing Rehabilitation Center. CDHospital based physician
groups are covered by this notice which include: Central DuPage
Emergency Physicians, Winfield Radiology Consultants and West
Central Anesthesiology Group Ltd.
Understanding Your Health Record/Information
Each time you visit a CD Health hospital, physician, or other
healthcare provider, a record of your visit is made. Typically,
this record contains your symptoms, examination and test results,
diagnoses, treatment, and a plan for future care or treatment.
This information, often referred to as your health or medical
record, serves as a:
- basis for planning your care and treatment
- means of communication among the many health professionals
who contribute to your care
- legal document describing the care you received
- means by which you or a third-party payer can verify that
services billed were actually provided
- a tool in educating heath professionals
- a source of information for public health officials charged
with improving the health of the nation
- a tool with which we can assess and continually work to
improve the care we render and the outcomes we achieve
Understanding what is in your record enables you to ensure
its accuracy. Understanding how your health information is used
helps you to better understand who, what, when, where, and why
others may access your health information and make more informed
decisions when authorizing disclosure to others. By reading
this notice and signing the acknowledgement form, you are allowing
CDHealth to use, access and disclose your health information
for treatment, payment, and health operations.
Your Health Information Rights
Although your health record is the physical property of the
healthcare practitioner or facility that compiled it, the information
belongs to you. You have the right to:
- obtain a paper copy of the notice of information practices
upon request
- inspect and copy your health record
- request an amendment to your health record
- obtain an accounting of disclosures of your health information
- request communication of your health information by alternative
means or to an alternative location
- revoke your authorization to use or disclose health information
except to the extent that action has already been taken
- request a restriction on certain uses and disclosures of
your information
Our Responsibilities
This organization is required to:
- maintain the privacy of your health information
- provide you with a notice as to our legal duties and privacy
practices with respect to information we collect and maintain
about you
- abide by the terms of this notice
- notify you if we are unable to agree to a requested restriction
- accommodate reasonable requests you may have to communicate
health information by alternative means or to an alternative
location
- Protect privacy about a deceased individual as long as the
information is maintained
We reserve the right to change our practices and to make the
new provisions effective for all protected health information
we maintain. Should our information practices change, we will
post this to our Web Site and provide a revised notice during
registration at your next visit. We will not use or disclose
your health information without your authorization, except as
described in this notice.
Confidentiality of mental health, alcohol and drug abuse
information
The confidentiality of mental health, alcohol and drug abuse
patient records maintained by this program is protected by federal
law and regulations. Generally, Central DuPage Health may not
acknowledge to anyone outside the program that a patient attends
the program, or disclose any information identifying a patient
as an alcohol or drug abuser unless one of the following conditions
is met:
- the patient gives written consent for disclosure
- the disclosure is allowed by a court order
- the disclosure is made to medical personnel in a medical
emergency or to qualified personnel for research, audit, or
program evaluation
Violation of the federal law and regulations by a program is
a crime. Suspected violations may be reported to appropriate
authorities in accordance with federal regulations.
Federal law and regulations do not protect any information
about a crime committed by a patient either at the program or
against any person who works for the program or about any threat
to commit such a crime.
Federal laws and regulations do not protect any information
about suspected abuse or neglect (of a child or an adult) from
being reported under state law to appropriate state or local
authorities.
For More Information or to Report a Problem
If have questions and would like additional information, you
may contact the HIPAA Program Office at 630-933-6308.
If you believe your privacy rights have been violated, you can
file a complaint with the CDHospital Patient Relations Department
at 630-933-6690. Additional information about filing a complaint
with the Office of Civil Rights can be found at www.hhs.gov/ocr/hipaa/.
There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health
Operations
We will use your health information for treatment.
For example: Information obtained by a nurse, physician, or
other member of your healthcare team will be recorded in your
record and used to determine the course of treatment that would
work best for you. Your physician will document in your record
his or her expectations of the members of your healthcare team.
Members of your healthcare team will then record the actions
they took and their observations. In that way, the physician
will know how you are responding to treatment. We will also
provide your physician or a subsequent healthcare provider with
copies of various reports that should assist him or her in treating
you after your discharge from our facility. We may contact you
to provide appointment reminders or treatment alternatives.
We will use your health information for payment.
For example: A bill may be sent to you or a third-party payer.
The information on or accompanying the bill may include information
that identifies you, as well as your diagnosis, procedures,
and supplies used.
We will use your health information for regular health
operations.
For example: Members of the medical staff, the risk or quality
improvement manager, or members of the quality improvement team
may use information in your health record to assess the care
and outcomes in your case and others like it. This information
will then be used in an effort to continually improve the quality
and effectiveness of the healthcare and service we provide.
Patient satisfaction surveys are used to determine how satisfied
you are with our service. This survey may be in the form of
a telephone call or a written survey.
Uses or Disclosures CDHealth may make without your Authorization
Business associates: There are some services provided
in our organization through contacts with business associates.
Examples include physician services in the emergency department,
anesthesiology and radiology, certain laboratory tests, and
a copy service we use when making copies of your health record.
When these services are contracted, we may disclose your health
information to our business associate so that they can perform
the job we've asked them to do and bill you or your third-party
payer for services rendered. To protect your health information,
however, we require the business associate to appropriately
safeguard your information.
Directory: Unless you notify us that you object, we
will use your name, location in the facility, general condition,
and religious affiliation for directory purposes. This information
may be provided to members of the clergy and, except for religious
affiliation, to other people who ask for you by name as well
as government agencies and disaster relief organizations in
the event of a disaster.
Notification: We may use or disclose information to
notify or assist in notifying a family member, personal representative,
or another person responsible for your care, your location,
and general condition.
Communication with family: Health professionals, using
their best judgement, may disclose to a family member, other
relative, close personal friend or any other person you identify,
health information relevant to that person's involvement in
your care or payment related to your care.
Minors: We will follow Illinois State Law as it relates
to 'personal representatives' or non-emancipated minors.
Research: We may disclose information to researchers
when there are established research protocols or where we have
obtained a waiver from an institutional review board.
Limited Data Set: We may use or disclose a limited data
set (i.e. in which certain identifying information has been
removed) of your protected health information for purpose of
research, public health, or health care operations. Any recipient
of that limited data set must agree to appropriately safeguard
your information.
Incidental Uses and Disclosures: We are permitted to
use and disclose information incidental to another use or disclosure
of your protected health information permitted or required under
law.
Medical examiners, Coroners, and Funeral directors:
We may disclose health information to medical examiners, coroners,
and funeral directors consistent with applicable law to carry
out their duties.
Organ procurement organizations: Consistent with applicable
law, we may disclose health information to organ procurement
organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue
donation and transplant.
Marketing: We may contact you to provide appointment
reminders or information about treatment alternatives or other
health-related benefits and services that may be of interest
to you. We do not provide patient information to other organizations.
Fund raising: We may contact you as part of a general
fund-raising effort in support of CDHealth.
Food and Drug Administration (FDA): We may disclose
to the FDA health information relative to adverse events with
respect to food, supplements, product and product defects, or
post marketing surveillance information to enable product recalls,
repairs, or replacement.
Workers compensation: We may disclose health information
to the extent authorized by and to the extent necessary to comply
with laws relating to workers compensation or other similar
programs established by law.
Public health: As required by law, we may disclose your
health information to public health or legal authorities charged
with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of
a correctional institution, we may disclose to the institution
or agents thereof health information necessary for your health
and the health and safety of other individuals.
Law enforcement: We may disclose health information
for law enforcement purposes as required by law or in response
to a valid subpoena.
Your Right to Inspect and Copy: You generally have the
right to inspect and obtain a copy of any protected health information
in your medical record, with the exception of psychotherapy
notes, information compiled in anticipation of use in a civil,
criminal or administrative proceeding and certain other health
information which the law restricts CDHealth from disseminating.
However, if you are a patient of certain types of facilities,
you may have a right to access your patient records or information
on an unqualified basis. Specifically, the following;
- If you are a patient at a facility that performs mammograms,
you have the right to access your original mammograms and
copies of your patient report on an unqualified basis.
- If you are a patient of a naprapath, acupuncturist or hospital,
you have the right to access your patient records on an unqualified
basis, upon written request.
Federal law makes provisions for your health information to
be released to an appropriate health oversight agency, public
health authority or attorney, provided that a work force member
or business associate believes in good faith that we have engaged
in unlawful conduct or have otherwise violated professional
or clinical standards and are potentially endangering one or
more patients, workers or the public.
Examples of Disclosures by Illinois State Law that require
specific Patient Authorization
In general, release of medical records is restricted except
where Federal or State Law allows. The following Medical Records
disclosures require your written permission:
- Patients with high blood pressure to the Illinois High Blood
Pressure Registry.
- Patients of an Advanced Practical Nurse to the Advanced
Practice Nursing Board/Department of Professional Regulation
- Patients of a podiatrist to the Podiatric Medical Licensing
Board.
- Patients of an impaired Physician (physical or mental)
to the Medical Disciplinary Board.
- Patients who are recipients of an HIV test.
- Patients who receive genetic testing may have results released
to you and to person you designate in writing to receive the
information. In the case of minors under 18 years of age,
parents/legal guardians maybe notified with written permission
except where allowed by law.
- Clients of a rape counselor; The counselor may not disclose
any communications or testify as a witness without your permission
unless withholding information presents an imminent danger
to you or another person.
- Victims of sexual assault: Evidence collection kits/photographs
may not be released to the Illinois State Police without permission.
Permission of parents or guardian are required for minors
under 13. If permission is refused for release of photographs
for a minor , then all existing photographs and negatives
shall be given to the parents/legal guardian.
- Residents of a Nursing Home Facility: Wynscape cannot allow
a person not directly involved in your care to be present
during a conversation about your health status without your
permission.
- Patients of CNS Home Health may not allow the Department
of Public Health to observe your care in your home without
your permission.
- CD Health may not notify parents/guardians of minors under
18 with a positive HIV result without your permission.
- CD Health professional may not notify parents/guardians
of minors seeking counseling for; drug or alcohol abuse without
your permission except to protect your safety or that of another
family member.
- Patients of a clinical psychologist: the psychologist may
not disclose any information he or she may have acquired while
attending to you unless they ensure that you understood the
possible uses and distribution of the information.
- CDHealth may not disclose your information regarding mental
health or developmental disability services without permission
except where Illinois law allows. Parents of minors from 12
years to 18 years may inspect and copy minors' records if
you are informed and do not object. Your therapist may also
object. Parents may petition a court for access in the circumstance
in which a therapist or a patient object.
- Clinical social worker, clinical licensed professional counselors,
marriage and family therapists may not disclose information
that they have acquired without your permission. Exceptions
include: for professional consultation; in the event of the
patient's death with permission of your personal representative;
when you intend to commit certain crimes or harmful acts;
or when you waive the privileged nature of the communications
by bringing public charges against the therapist.
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