Notice of Privacy Practices

DRAFT — not yet published. The content below follows the federal model language and must be reviewed and completed by the practice before it goes live. Every [CONFIRM: …] marker is a fact only the practice can supply.

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.

Effective date: [CONFIRM: effective date]

This notice applies to Immediate Care Center of Westmont, including Urgent Care Center of Westmont at 29 N Cass Ave, Ste A, Westmont, IL 60559 and Immediate Care Center of Westmont inside Jewel-Osco at 4 E Ogden Ave, Westmont, IL 60559.

Our commitment

We are required by law to protect the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. We must also notify you if a breach of your unsecured protected health information occurs.

How we may use and share your health information

Treatment. To provide, coordinate and manage your care, including sharing information with other clinicians, laboratories, pharmacies and specialists involved in your treatment.
Payment. To bill and collect payment from you, your insurer or another payer, including verifying coverage and obtaining prior authorisation.
Health care operations. For quality assessment, staff review and training, licensing, and business management.
Appointment and care reminders, treatment alternatives and health-related benefits and services.
Where the law requires or permits it, including public health activities, reporting suspected abuse or neglect, health oversight, judicial and administrative proceedings, law enforcement, organ donation, coroners and funeral directors, workers compensation, and to avert a serious threat to health or safety.

Uses and disclosures not described in this notice will be made only with your written authorisation, which you may revoke at any time in writing. Most uses and disclosures of psychotherapy notes, uses for marketing, and any sale of your information require your written authorisation.

Your rights

Get a copy of your medical and billing records, usually within 30 days, in the form you ask for if we can readily produce it. We may charge a reasonable, cost-based fee.
Ask us to correct information you believe is incorrect or incomplete. We may say no, and if we do we will tell you why in writing.
Request confidential communications — for example, to be contacted at a different address or number. We will say yes to reasonable requests.
Ask us to limit what we use or share. We are not required to agree, except that if you pay for a service in full out of pocket, you can ask us not to share that information with your health insurer, and we must agree unless the law requires the disclosure.
Get a list of disclosures we have made in the six years before your request, other than for treatment, payment and health care operations, and certain other disclosures.
Get a paper copy of this notice, even if you agreed to receive it electronically.
Choose someone to act for you — a personal representative with legal authority may exercise your rights.
File a complaint if you believe your rights have been violated.

How to exercise your rights or complain

Contact our Privacy Officer:

Privacy Officer: Dr. Amer [CONFIRM: full name and title exactly as it should appear]
Address: [CONFIRM: mailing address for privacy requests]
Phone: (630) 324-6825
Email: [CONFIRM: privacy contact email]

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, D.C. 20201, by calling 1-877-696-6775, or at hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we hold about you. The new notice will be available on request, in our offices, and on this website.