This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review this notice carefully.
We are committed to keep your medical information confidential. This notice describes the privacy practices of the Institute of Physical Medicine and Rehabilitation and our Business Associates with whom we may share information.
We are required by law to maintain the privacy of your medical information and to provide you with this Notice of our legal duties and privacy practices with respect to your medical information. When we use or disclose your medical information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
I. Permissible Uses and Disclosures of Your Medical Information without Your Written Authorization
We may use and disclose your medical information for the following reasons:
Treatment. To provide treatment and other services to you – for example, to diagnose and treat your injury or illness. In addition, 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 may also disclose your medical information to other providers involved in your treatment.
Payment. To obtain payment for services that we provide to you—for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care ("Your Payor") and to verify that Your Payor will pay for health care.
Health Care Operations. For example, we may use your medical information to evaluate the quality and competence of our physicians, nurses and other health care workers and internal administration and planning. We may also disclose your medical information to your other health care providers when such medical information is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
Disclosure to Family, Close Friends and Other Caregivers. To a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure can not practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclosure your medical information in order to notify (or assist in notifying) such persons of your location, general condition or death.
Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of the Rehabilitation Foundation of IPMR. We may disclose to our fundraising department your name; address and phone number and dates on which we provided health care to you. If you wish to make a tax-deductible contribution now or do not want to receive any fundraising requests in the future, you may contact the Foundation’s Director of Development at (309) 692-8110.
Other Possible Disclosures. We may also use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you for Public Health Activities for the purpose of preventing or controlling diseases; abuse and neglect, to a governmental authority if we reasonably believe you are a victim of abuse, neglect or domestic violence; health oversight activities or inspections, to a health oversight agency that oversees the health care system; judicial, administrative and law enforcement purposes, for example, in response to a subpoena or a request by a law enforcement officer; and we may also disclose your medical information for research studies, workers’ compensation purposes, your health and safety, and when it is required by law.
II. Uses and Disclosures Requiring Your Written Authorization
For any purpose other than the ones described above in Section I, we may only use or disclose your medical information when you grant us your written authorization on our authorization form. For instance, you will need to execute an authorization form before we can send your medical information to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Marketing. We must also obtain your written authorization prior to using your medical information to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining your authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your authorization.) In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without your authorization.
Highly Confidential Information. In addition, federal and Illinois law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including the subset of your medical information that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV /AIDs testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; or (9) is about sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.
III. Your Rights Regarding Your Medical Information
For Further Information and Complaints. If you have questions about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your medical information, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services. Upon request, our Privacy Office will provide you with the correct address. We will not retaliate against you if you file a complaint.
Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your medical information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Medical Records Department and submit the completed form. We will send you a written response.
Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your medical information by alternative means of communication or at alternative locations, for example, other than your home address.
Right to Revoke Your Authorization. You may revoke Your Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please submit your request to our Medical Records Department at the same address as listed below. If you request copies, you will be charged a fee.
Right to Amend Your Records. You have the right to request that we amend your medical or billing records. If you desire to amend your records, please obtain an amendment request form from our Medical Records Department and return the completed form. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive an Accounting. You may obtain an accounting of certain disclosures of your medical information made by us in the six years prior to your request. This does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged for the additional account statements.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
IV. Right to Change Terms of this Notice
We may change this Notice at any time. If we change this Notice, we may make the new notice terms effective for all medical information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our patient waiting areas and on our Internet site at www.ipmr.org. You also may obtain any new notice by contacting our Privacy Office.
V. Contact Address / Phone Number
You may contact our Privacy Office or our Medical Records Department at:
Institute of Physical Medicine and Rehabilitation
6501 N. Sheridan Road
Peoria IL 61614
Phone: (309) 692-8110