Revised April 2003
Southern Illinois Acupuncture
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.
Purpose of This Notice
This notice tells you about how we use and disclose
your medical information.
It tells you about your rights and our responsibilities to protect the privacy
of your medical information. It also tells you how to complain to us, or the
government if you believe that we have violated any of your rights or any of
our responsibilities.
We are required by law to maintain the privacy of your medical information.
We must provide you with a copy of this notice and get your written acknowledgement
of its receipt.
We must follow the terms of this notice that are currently in effect. We will
tell you if we change this notice. A copy of the revised notice will be available
upon request or posted at our location or on our website. We may change our
practices and those changes may apply to medical information we already have
about you as well as any new information.
This notice will be given to you on the date that you first receive medical
products or treatment from Southern Illinois Acupunture. In an emergency, we
will give you the notice as soon as possible after the emergency treatment has
been given.
How We Use or Disclose Your Medical Information For Treatment
We will use medical information about you to provide you with treatment
and services. We may share this information with members of our healthcare staff
or with others involved in your care such as doctors, nurses, or health care
facilities. We may also disclose your health information to a member of your
family or other person who is involved in your care.
For Payment
We may use or disclose your medical information to bill and collect
payment for the services we provided to you. For example, we may need to give
your health insurance plan information about your diagnosis, treatment and supplies
used. We may also contact your insurance plan to confirm your coverage or to
request prior approval for a planned treatment or service.
Health Care Operations
We may use or disclose your medical information for operational purposes.
For example, we may use your medical information to evaluate our services, including
the performance of our staff in caring for you. We may also use this information
to learn how to continually improve the quality and effectiveness of the health
care services that we provide to you. There are some services that are provided
for us by our business associates such as accountants, consultants and attorneys.
Whenever we share information with our business associates we will have a written
contract with them that requires that they protect the privacy of your medical
information.
Other Use and Disclosures of Your Medical Information
Fund-raising -Your name and address and the dates you received treatment
or services may be added to a mailing list of patients in order to invite you
to a fund-raising event or to send you a newsletter. If you do not want to receive
these communications, please notify us in writing.
Treatment Alternatives - We may use and disclose medical information about you
to contact you about other health care treatment that is available to you. If
you do not want to receive these communications, please notify us in writing.
Health Related Benefits and Services - We may use and disclose medical information
about you to contact you about other health care benefits or services that may
interest you. If you do not want to receive these communications, please notify
us in writing.
Individuals Involved in Your Care - We may disclose medical information about
you to a family member, other relative, close friend or any other person identified
by you if they are involved in your care or payments related to your care. We
may also use or disclose medical information about you to notify those persons
of your location, general condition or death. If there is a family member, other
relative or close friend to whom you do not want us to disclose medical information
about you, please notify us in writing.
Use or Disclosures That Are Required or Permitted by Law
Disaster Relief - We may use or disclose medical
information about you assist in disaster relief efforts. This will be done to
notify family members or others of your location, general condition or death
in the event of a natural or man-made disaster.
Required by Law - We may use or disclose medical information about you when
we are required to do so by law.
Victims of Abuse, Neglect or Domestic Violence - We may disclose medical information
about you to a government agency if we believe you are the victim of abuse,
neglect or domestic violence.
Health Oversight Activities - We may disclose medical information about you
to a health oversight agency.
Food and Drug Administration - We may disclose medical information about you
to monitor drugs or devices controlled by the Food and Drug Administration.
Legal Activities - We may disclose medical information about you in response
to a court proceeding. We may also disclose medical information about you in
response to a subpoena or other legal process. Efforts may be made to contact
you prior to a disclosure of your PHI by the party seeking the information.
Disclosures for Law Enforcement Purposes - We may disclose information about
you to law enforcement officials for law enforcement purposes:
· As required by law.
· In response to a court order or other legal proceeding.
· To identify or locate a suspect, fugitive, material witness or missing person.
· When information is requested about an actual or suspected victim of a crime.
· To report a death as a result of possible criminal conduct.
· About crimes that occur on our premises.
· To report a crime in emergency circumstances.
Funeral Directors, Coroners and Medical Examiners
- We may disclose medical information about you as necessary to allow these
individuals to carry out their responsibilities.
Organ Donation - We may disclose medical information about you to organ procurement
organizations if you are an organ donor.
Workers' Compensation - We may disclose medical information about you to comply
with workers' compensation laws that provide benefits for work-related injuries
or illnesses.
Public Health or Safety - We may use or disclose medical information about you
if we believe it is necessary to prevent a threat to the health or safety of
a person or the general public.
Military - If you are a member of the Armed Forces, we may use and disclose
medical information about you to your military command.
National Security and Intelligence - We may disclose medical information about
you to authorized federal officials for national security and intelligence activities.
Security Clearance - We may use medical information about you for a required
security clearance.
Research - We may disclose your medical information to researchers under certain
limited circumstances.
Uses or Disclosures That Require Your Authorization
Other uses and disclosures will be made only with your written authorization.
You may cancel an authorization at any time by notifying us in writing of your
desire to cancel it. If you cancel an authorization it will not have any affect
on information that we have already disclosed. Examples of uses or disclosures
that may require your written authorization include the following: A request
to provide certain medical information to a drug company for marketing purposes.
Your Rights
The information contained in your health or medical record is the physical
property of Southren Illinois Acupuncture. The information in it belongs to
you. You have the following rights:
Right to Request Restrictions - You have the right to ask us not to use or disclose
your medical information for a particular reason related to treatment, payment
or our operations. You may ask that family members or other individuals not
be informed of specific medical information. That request must be made in writing
to us. We do not have to agree to your request. If we agree to your request,
we must keep the agreement, except in the case of a medical emergency. Either
you or Southern Illinois Acupuncture can stop a restriction at any time.
Right to Receive Confidential Communications - You have the right to ask that
we communicate with you in a certain manner or at a certain place. If you want
to request confidential communications the request must be made in writing to
us. We must agree to your request if it is reasonable.
Right to Inspect and Copy Your Medical Information - You have the right to request
to inspect and obtain a copy of your medical information. You must submit your
request in writing to us. If you request a copy of the information or that we
provide you with a summary of the information we may charge a fee for the costs
of copying, summarizing and/or mailing it to you. If we agree to your request
we will tell you. We may deny your request under certain limited circumstances.
If your request is denied, we will let you know in writing and you may be able
to request a review of our denial.
Right to Request Amendments to Your Medical Information - You have the right
to request that we correct your medical information. If you believe that any
medical information in your record is incorrect or that important information
is missing, you must submit your request for an amendment in writing to us.
We do not have to agree to your request. If we deny your request we will tell
you why. You have the right to submit a statement disagreeing with our decision.
We may deny your request if we determine that the information:
· Was not created by us
· Is not part of the medical information that we maintain
· Is in records that you are not allowed to inspect and copy
· Is already accurate or complete
Right To An Accounting of Disclosures of Health
Information - You have the right to find out what disclosures of your medical
information have been made. The list of disclosures is called an accounting.
The accounting may be for up to six (6) years prior to the date on which you
request the accounting, but can not include disclosures before April 14, 2003.
We are not required to include disclosures for treatment, payment or healthcare
operations or certain other exceptions. Requests for an accounting of disclosures
must be submitted in writing to us. You are entitled to one free accounting
in any twelve (12) month period. We may charge you for the cost of providing
additional accountings. If there will be a charge we will notify you in advance.
Right To Obtain a Copy of the Notice - You have the right to request and get
a paper copy of this notice and any revisions we make to the notice at any time.
Complaints
You have the right to complain to us and to the United States Secretary
of Health and Human Services if you believe we have violated your privacy rights.
There is no risk in filing a complaint.
To file a complaint with us, contact by phone or by mail:
Dr. Ying Li
Southern Illinois Acupuncture
800 W. Main Street
Carbondale, IL 62901
618-549-0750
dryingli@chineseneedle.com
To file a complaint with the United States Secretary of Health and Human Services send your complaint to him or her in care of:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington DC 20201
Questions and Information
If you have any questions or want more information about this Notice of Privacy Practices, please contact:
Dr. Ying Li
Southern Illinois Acupuncture
800 W. Main Street
Carbondale, IL 62901
618-549-0750
dryingli@chineseneedle.com
By phone with questions or with written requests for information as defined under the Your Rights section of this notice. Complaints or questions may be made by phone or in writing.