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 practice (Paul Revis M.D., S.C.) creates a medical record of your health information in order to treat you, receive payment for services delivered, and to comply with certain policies and laws. We are also required by law to provide you with this Notice of our legal duties and privacy practices. In addition, the law requires us to ask you to sign an Acknowledgment that you have received this Notice.

We are required by federal and state law to maintain the privacy of your medical information, and we take this responsibility very seriously. Medical information is called “protected health information” or “PHI”. We are also required by law to notify you if you are affected by a breach of your unsecured PHI.

The following is a list of some of the types of uses and disclosures of PHI that may occur legally:

Treatment: We obtain health information, or PHI, about you in order to properly treat you. We may also send your PHI to another physician, facility, or counselor to which we refer you for treatment, care, procedures, or testing. We may also use your PHI to contact you to tell you about alternative treatments, or other health related benefits we offer. If you have a friend or family member involved in your care, we may give them PHI about you.

Payment: We use PHI to obtain payment for the services that we render. For example, we send PHI to Medicare, Medicaid, and private insurance plans to obtain payment for our services.

Health Care Operations: We use PHI for our general operations. For example, we may use your PHI in determining whether we are providing adequate treatment to our patients. We use PHI to schedule appointment, take messages, and to remind you of an upcoming appointment.

Legal Requirements: We may use and disclose your PHI as required or authorized by law. For example, we may use or disclose your PHI for the following reasons:

Public Health: We may disclose your health information to prevent or control disease, injury or disability, to report births and deaths, to report reactions or side effects form medications or medical devices, or to report suspected cases of abuse or neglect.
Health Oversight Activities We may use or disclose your PHI to state agencies and to federal government authorities when required to do so. We may use and disclose your health information in order to assist others in determining your eligibility for public benefit programs and to coordinate delivery of those programs. For example, we must give PHI to the Secretary of Health and Human Services in a investigation into our compliance with the federal privacy rule.
Judicial and Administrative Proceedings: We may use and disclose your PHI in judicial and administrative proceedings. Efforts may be made to contact you prior to a disclosure of your PHI to the party seeking information.
Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant to a court order, warrant, subpoena, summons, or similar process. We may use and disclose PHI to locate someone who is missing, to identify a crime victim, to report a death, to report suspected criminal activity at our office, or in and emergency.
Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or someone else from getting hurt or injured.
Work-Related Injuries: We may use or disclose PHI to an employer if the employer is conducting medical workplace surveillance or to evaluate possible work-related injuries.
Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or medical examiner in some situations. For example, PHI may be needed to identify a deceased person or to determine a cause of death. Funeral directors may need PHI to carry out their duties.
Armed Forces: We may use or disclose the PHI of Armed Forces personnel to the military for proper execution of a military mission. We may also use and disclose PHI to the Department of Veteran Affairs to determine eligibility for benefits.
National Security and Intelligence: We may use or disclose PHI to maintain the safety of the President or other protected officials. We may use or disclose PHI for the conduct of national intelligence activities.
Correctional Institutions and Custodial Situations: We may use or disclose PHI to correctional institutions or law enforcement custodians for the safety of individuals at the correctional institution, those that are responsible for transporting inmates, and others.
Research: You will need to sign an Authorization form before we use or disclose PHI for research purposes except in limited situations. For example, if you want to participate in research or a clinical study, an Authorization form must be signed.
Fundraising: We do not engage in fundraising activities. We do not engage in marketing activities, we would need a separate authorization from you to do so. If we obtain your e-mail, we will not sell it or release it for any marketing purposes.
Immunizations: If we obtain and document your verbal or written agreement to do so, we may release proof of immunization to a school where you are a student or prospective student.

Illinois Law: Illinois law has certain requirements that govern the use or disclosure of your PHI. In order for us to release information about mental health treatment, genetic information, your AIDS/HIV status, and alcohol or drug abuse treatment, you will be required to sign a separate Authorization form unless state law allows us to make the specific type of use or disclosure without your authorization.

Your Rights: You have certain rights under federal and state laws relating to your PHI. Some of these rights are described below:

Restrictions: You have a right to request restrictions on how your PHI is used for purposes of treatment, payment, and health care operations. We are not required to accommodate your request, except as required by law. The practice is required to comply with your request for restrictions on the use or disclosure of your PHI to health plans for payment or health care operation purposes when the practice has been paid out of pocket in full and the practice has been notified of the request for restrictions in writing, and the disclosure is not required by law.
Communications: You have a right to receive confidential communications about your PHI. For example, you may request that we only call or contact you at home. If your request is reasonable, it may be accepted.
Inspect and Access: You have a right to inspect your health information. This information includes billing and medical record information. You may not inspect your medical record in some cases. If your request to inspect your record is denied, we will send you a letter explaining why the request has been denied, and giving you your options to appeal the decision. When approved, you may have a paper copy of your medical record in most situations. We may charge you a reasonable fee as determined by law for making copies and mailing them to you, if you ask that they be mailed.
Amendments of Your Records: If you believe there is an error in your PHI, you have the right to request that we amend your PHI and make corrections. We are not required to agree with your request to amend.
Accounting of Disclosures: You have a right to receive an accounting of disclosures that that we have made of your PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization.
Copy of Notice: You have a right to obtain a paper copy of this Notice, even if you originally received the notice electronically. We have also posted this Notice at our offices.
Complaints: If you feel that your privacy rights have been violated, you may file a complaint with us by sending a letter to:

Privacy Officer
Paul Revis M.D., S.C.
1055 Featherstone Road
Rockford, IL 61107

OR you may file a complaint with the Secretary of Health and Human Services in Washington, D.C.
Authorizations: We are required to obtain your written Authorization when we use or disclose your PHI in ways not described in this Notice or when we use or disclose your PHI as follows: For marketing purposes, for the sale of your PHI, or for uses and disclosures of psychotherapy notes (except certain uses and disclosures for treatment, payment, or health care operations). You may revoke your Authorization at any time in writing, except to the extent that we have already acted on our Authorization.

We are required to abide with terms of this Notice currently in effect, however, we may change this Notice. If we materially change this Notice, you can get a revised Notice by stopping by our office to pick up a copy during business hours. Changes to the Notice are applicable to the health information we already have, unless stated otherwise.

EFFECTIVE DATE: 9/23/2013