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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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. PHI is information that may identify you and that relates to your past, present, future physical or mental health, condition and related health care services. This Notice also describes your rights to access and control your PHI.
This office is required by law to follow the terms of this Notice of Privacy Practices and to provide you with a copy of this notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice at any time and make the new Notice effective for all PHI that we maintain at that time. Upon request, we will provide you with any revised Notice of Privacy Practices to you.
The office will obtain your written authorization before using or disclosing PHI about you for purposes other than those provide for herein or as otherwise permitted or required by law. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you, except to the extent that we have already taken action in reliance to the authorization.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your PHI may be used and disclosed by our physicians, nurses, office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you.
The practice reasonably ensures that the PHI it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose.
Unless you object, we may disclose to a family member, relative or close friend your PHI that directly relates to the person’s involvement in your care or payment for care. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. In addition, PHI may be disclosed for notification purposes to public or private entities authorized by law to assist in disaster relief efforts.
We may use or disclose your PHI in an emergency treatment situation, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.
The following are examples of the types of uses and disclosures of your PHI that our office is permitted to make without requiring your written authorization. These examples are not meant to be exhaustive, but describe some of the types of uses and disclosures that may be made by our office.
Treatment. We will use and disclose your PHI to provide, coordinate or manage your health care and any related services, including releasing information to other health care providers involved in your care.
Payment. We will use and disclose your PHI, as needed, as it relates to all activities associated with getting reimbursed for services provided, including submission of claims to insurance companies and providing any information required by the insurance company needed to determine if they should pay the claim. In worker’s compensation claims and personal injury claims, we will use and disclose your PHI, as needed, to your attorneys and their staff for purposes of getting reimbursed for services provided and/or assisting them in your claim.
Health Care Operations. We may use and disclose, as needed, your PHI in order to support the business activities of our practices, including but not limited to, quality assessment and improvement activities, training of staff, specified insurance functions, business planning and development and to our business associates that perform such activities as billing, collecting, consulting and accounting. To protect PHI about you, we will require the business associates to appropriately safeguard the PHI.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives or Health-Related Products or Services. We may use and disclose medical information to tell you about possible treatment options or alternatives, or about our health-related products or services that may be of interest to you.
As Required by Law. We may disclose your PHI as required by the relevant law and said disclosure will be limited to the requirements of the law or subpoena.
Public Health Activities. As required by law, we may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Victims or Abuse, Neglect or Domestic Violence. As required by law, we may disclose PHI about you to appropriate government authorities regarding victims of abuse, neglect or domestic violence.
Health Oversight Activities. As required by law, we may disclose PHI about you to health oversight agencies which may include audits and investigations necessary for oversight of the health care system and government benefit programs.
Judicial and Administrative Proceedings. We may disclose your PHI as required by an order from a court or administrative tribunal and said disclosure will be limited to the requirements of the order or subpoena. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process to someone involved in the dispute, but only if efforts have been made to tell you about the request (which may include a written notice to you) or to obtain an order protecting the information requested.
Law Enforcement Purposes. We may disclose PHI about you for law enforcement purposes as required by law in response to a valid subpoena or other legal process or in limited circumstances related to the reporting or investigation of a crime.
Decedents. We may disclose your PHI to funeral directors, as needed, and coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.
Organ Donation. We may disclose your PHI to facilitate the donation and transplantation of cadaveric organs, eyes and tissue.
Research. The practice does not engage in any research activities that require it to use or disclose protected health information.
Serious Threat to Health and Safety. We may disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Essential Government Functions. We may use or disclose protected PHI for certain essential functions which may include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determination for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.
Workers’ Compensation. We may use and disclose PHI about you as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses.
INDIVIDUAL RIGHTS
The following is a statement of your rights with respect to PHI effective as of November 1, 2021.
Right to Access. You have the right to access and copy PHI about you contained in a designated record set for as long as the office maintains the PHI. The designated record set usually contains medical and billing records as well as any other records that the practice uses for making decisions about you. To inspect or copy PHI about you, you must send a written request to the
Privacy Officer at Ascend Pain and Wellness. You may obtain the copy in paper or electronic format. If you request that we send the electronic copy directly to someone else, we will do so. We may charge you a fee for the cost of copying, mailing, supplies and staff time that are necessary to fulfill your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed. We will comply with the outcome of the review.
Right to An Accounting. You have the right to receive an accounting of the disclosures we have made of PHI about you other than treatment, payment or health care operations. The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friend or family members involved in your case, disclosures for notification, restrictions and limitations. To request an accounting, you must submit a request in writing to the Privacy Officer at Ascend Pain and Wellness. Your request must specify a time period, but may not be longer than 6 years.
Right to Restrict. You have the right to request additional restrictions on our use or disclosure of PHI about you by sending a written request to the Privacy Officer at Ascend Pain and Wellness and specifying the requested restriction. We are not required to agree to those restrictions but if we do, we are required to abide by these instructions (except in emergency situations). In addition, if you have paid out of pocket in full for a health care service, we must agree not to disclose medical information above that service to a health plan for payment or health care operation.
Right to Confidential Communications. You have the right to request that we communicate with you about your PHI by alternative means or at alternate locations. To request confidential communication of PHI about you, you must submit a request in writing to the Privacy Officer at Ascend Pain and Wellness. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.
Right to Request Amendment. You have the right to request an amendment of your PHI within a designated record set for as long as we maintain this information. To request an amendment, you must send a written request to the Privacy Officer at Ascend Pain and Wellness with an explanation of what information is to be amended and why. In certain cases, we may deny your request for amendment and if we deny your request, you have the right to submit a written statement about anything in your record that you believe is incomplete or incorrect.
Right to a Copy of this Notice. You have a right to request a copy of this Notice at any time. To obtain a copy of this notice, please contact the Privacy Officer at Ascend Pain and Wellness for a copy of the Notice.
Questions and Complaints. If you want more information about our privacy practices or have any questions or concerns, please contact the Company Privacy Officer. Our Privacy Officer is also our Chief Operating Officer who can be contacted at (708) 550-7005. If you believe your privacy rights have been violated, you can file a complaint with the US Department of Health and Human Services at hhs.gov or (877) 696-6775.
PATIENT’S BILL OF RIGHTS AND RESPONSIBILITES
Rights
The observance of the following guidelines will provide more effective patient care and greater satisfaction for the patient, the physician and the individuals that make up the office organization. It is in recognition of these factors that these rights are affirmed.
The patient has the right to considerate and respectful care; cultural, psychosocial, spiritual, personal values, beliefs, and preferences will be respected, and care will be given in a safe setting. Patients with vision, speech, hearing, language, and cognitive impairments have the right to effective communication.
The patient has the right to receive from his/her physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily be limited to the specific procedure and/or treatment, the medically= significant risks involved, and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternative, the patient has the right to know the name of the person(s) responsible for the procedures and/or treatment as well as the person(s) responsible for their sedation and anesthesia. The patient also has the right to consent to production of photographs, videotapes, or images during their procedure and to any research, investigation or clinical trials.
The patient has the right to every consideration of his/her privacy concerning his/her medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to expect that all communications and records pertaining to his/her care should be treated as confidential. Those not directly involved in his/her care must have permission of the patient to be present.
The patient has the right to obtain from the physician complete current information concerning his/her diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand. The patient has the right to be involved in decisions about their care, treatment and services and the patient has the right to have their pain assessed, managed, and treated as effectively as possible.
The patient has the right, and when appropriate, the patient’s family to be informed of unanticipated outcomes of care, treatment, and services that relate to sentinel or adverse reviewable events.
The patient has the right to expect that within its capacity, this ambulatory facility must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically permissible, a patient may be transferred to another facility only after he/she has received complete information and explanation concerning the needs for and alternatives to such a transfer.
The patient has the right to obtain information as to any relationship of this facility to other health care and educational institutions insofar as his/her care is concerned. The patient has the right to obtain information as to the existence of any professional relationships among individuals, by name, which is treating him/her.
The patient has the right to expect reasonable continuity of care. The patient has the right to expect that this facility will provide a mechanism whereby he/she is informed by his physician of the patient’s continuing health care requirements following discharge.
If a patient is adjudged incompetent under applicable State health and safety laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under State law to act on the patient's behalf. Such a family member or surrogate must prove legal authority to represent the patient via legal guardianship, proof of health care proxy or power of attorney. Proof of legal authority must be presented before treatment is rendered.
Additionally, if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State law may exercise the patient's rights to the extent allowed by State law.
The patient has the right to know the mechanisms for making suggestions or grievances as well as the complaint resolution process. If you information have any questions, concerns, or suggestions, please contact either the OR Coordinator or the Patient Advocate, Privacy Officer and Grievance Officer (who is also our Chief Operating Officer) both can be contacted at (708) 550-7005. You may also contact the Illinois Department of Public Health 122 S. Michigan Ave., Chicago, IL 60603.
The patient has the right to change their choice of physician.
The patient has the right to refuse care, treatment, and services in accordance with law and regulation.
The patient has the right to dispute information in their medical record
The patient has the right to examine and receive an explanation of his/her bill and to expect ethically billing practices.
The patient has the right to exercise all rights without discrimination or reprisal, any type of abuse or harassment.
Responsibilities
The patient has the responsibility to provide the physician with the most accurate and complete information regarding present complaints, past illnesses, hospitalizations, medications, allergies and unexpected changes in the patient’s condition.
The patient should provide the facility staff with information regarding their expectations or and satisfaction with the facility.
The patient is responsible for asking questions when they do not understand their care, treatment or services or what they are expected to do.
If the plan of care is agreed upon, the patient has the responsibility to follow the plan of care or express concerns with compliance. The patient and family are responsible for following the preoperative and post discharge care plan. The patient and family are responsible for the outcomes if they do not follow the care plan.
The patient is responsible to provide an adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by his/her physician.
The patient is responsible to inform his/her physician about any living will, medical power of attorney, “Do Not Resuscitate” or other directive that could affect his/her care.
The patient and family are responsible for following the practice’s rules and regulations concerning patient care and conduct
Patients and families are responsible for being considerate of the practice’s staff and patients and their property.
The patient and family are responsible for promptly meeting any financial obligation agreed to with the practice.
