Notice of Privacy Practice

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

Chicago Family Health Center and all associates at all locations are required by law to maintain the privacy of patients’ Protected Health Information (PHI) and to provide individuals with the following Notice of the legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and these new terms will affect all PHI that we maintain at that time.

In certain circumstances we may use and disclose PHI about you without your written consent:

For Treatment: We will use health information about you to provide you with medical treatment or services. We will disclose PHI about you to providers, nurses, technicians, students in health care training programs, or other personnel who are involved in taking care of you. Different departments of Chicago Family Health Center may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information about you to people outside of Chicago Family Health Center who provide your medical care like other providers.

For Payment: We will use and disclose information to other health care providers to assist in the payment of your bills. We will use it to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment.

For Health Care Operations: We may use and disclose PHI about you for the purpose of our business operations. These business uses and disclosures are necessary to make sure that our patients receive quality care and cost effective services. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of our staff, contracted employees and students in caring for you.

Business Associates: We may use or disclose your PHI to an outside company that assists us in operating our health system. They perform various services for us. This includes, but is not limited to, auditing, legal services, and consulting services. These outside companies are called “business associates” and they contract with us to keep any PHI received from us confidential in the same way we do. These companies may create or receive PHI on our behalf.

Family Members and Friends: If you agree, does not object or we reasonably infer that there is no objection, we may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest under the circumstances. We may disclose PHI to a family member, relative, or another person who was involved in the health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to Chicago Family Health Center. But you also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care.

Appointments: We may use and disclose PHI to contact you for appointment reminders and to communicate necessary information about your appointment.

Fundraising Activities: We may use PHI, such as your name, address, phone number, the dates you received services, your treating physician, outcome information, and health insurance status to contact you to raise money for Chicago Family Health Center interests. We may share this information with a foundation associated with Chicago Family

Coroners, Medical Examiners and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release your PHI to a funeral director, as necessary, to carry out his/her duties.

Organ, Eye and Tissue Donation: We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.

Research: Chicago Family Health Center may use and share your health information for certain kinds of research. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. In some instances, the law allows us to do some research using your PHI without your approval.

Workers’ Compensation: We will disclose your health information that is reasonably related to a worker’s compensation illness or injury following written request by your employer, worker’s compensation insurer, or their representative.

Employer Sponsored Health and Wellness Services: We maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site. We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care.

Other Uses and Disclosures of PHI Permitted or Required by Law

Psychotherapy Notes: Under most circumstances, without your written authorization we may not disclose the notes a mental health professional took during a counseling session. However, we may disclose such notes for treatment and payment purposes, for state and federal oversight of the mental health professional, for the purposes of medical examiners and coroners, to avert a serious threat to health or safety, or as otherwise authorized by law.

Other uses and disclosures of your PHI that are not described above will be made only with your written authorization. If you provide Chicago Family Health Center with an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of PHI. However, the revocation will not be effective for information that we have used or disclosed in reliance on the authorization.

Your Rights Regarding Your PHI:

The Right to Access to Your Own Health Information: You have the right to inspect and copy most of your protected health information for as long as we maintain it as required by law. All requests for access must be made in writing. We may charge you a nominal fee for each page copied and postage if applicable. You also have the right to ask for a summary of this information. If you request a summary, we may charge you a nominal fee. Please contact Chicago Family Health Center Health Information/Medical Records Department with any questions or requests.

Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of your PHI. We are not required to agree to your request in most cases. But if Chicago Family Health Center agrees to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment. Chicago Family Health Center will agree to restrict disclosure of PHI about an individual to a health plan if the purpose of the disclosure is to carry out payment or health care operations and the PHI pertains solely to a service for which the individual, or a person other than the health plan, has paid Chicago Family Health Center for in full. For example, if a patient pays for a service completely out of pocket and asks Chicago Family Health Center not to tell his/her insurance company about it, we will abide by this request. A request for restriction should be made in writing. To request a restriction you must contact our Health Information/Medical Records Department. We reserve the right to terminate any previously agreed-to restrictions (other than a restriction we are required to agree to by law). We will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to PHI created after we inform you of the termination.

Right to Request Confidential Communications: If you believe that a disclosure of all or part of your PHI may endanger you, you may request in writing that we communicate with you in an alternative manner or at an alternative location. For example, you may ask that all communications be sent to your work address. Your request must specify the alternative means or location for communication with you. It also must state that the disclosure of all or part of the PHI in a manner inconsistent with your instructions would put you in danger. We will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your protected health information could endanger you.

Right to be notified of a Breach: You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of unsecured protected health information involving your medical information.

Right to Inspect and Copy: You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to our Health Information/Medical Records Department. For copies of your PHI, requests must go to the Health Information/Medical Records Department. For PHI in a designated record set that is maintained in an electronic format, you can request an electronic copy of such information. There may be a charge for these copies.

Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as Chicago Family Health Center maintains the information. Requests for amending your PHI should be made to the Health Information/Medical Records Department. Chicago Family Health Center personnel who maintain the information will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to an Accounting: With some exceptions, you have the right to receive an accounting of certain disclosures of your PHI. A nominal fee will be charged.

Complaints: You may submit any complaints with respect to violations of your privacy rights to the Chicago Family Health Center’s Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services if you feel that your rights have been violated. There will be no retaliation from Chicago Family Health Center for making a complaint.

Changes to this Notice If we make a material change to this Notice, we will provide a revised Notice available on our website at www.chicagofamilyhealth.org

Contact Information Unless otherwise specified, to exercise any of the rights described in this Notice, for more information, or to file a complaint, please contact the Privacy Officer at ext. 1076 or by direct dial at 773-364-2261.

Revised April 2015

Rev Jan 2018