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 takes effect on April 14, 2003 and remains in effect until we replace it.

Lincolnwood Acupuncture & Chiropractic Center, P.C. (LACC) is committed to maintaining the privacy of your protected health information (PHI), which includes information about your health condition and the care and treatment you receive from this office. The creation of a record detailing the care and services you receive helps this office to provide you with quality care. This notice also details your rights regarding your PHI.

USES AND DISCLOSES OF YOUR MEDICAL INFORMATION

The following section describes different ways that LACC may use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your written authorization. Any written authorization may be revoked at any time by writing to us.

1. Treatment- In order to provide you with the health care you need, LACC may provide your PHI to those health care professionals, whether on our staff or not, directly involved in your care so that they may understand your health condition and needs. For example, a physician treating you for lower back pain may need to know the results of your latest examination findings by this office.



2. Payment- In order to get paid for services provided to you, LACC may provide your PHI, directly or through a billing service, to appropriate third payers, pursuant to their billing and payment requirements. For example, LACC may need to provide the Medicare program with information about health care services that you may receive from this office so that we can be properly reimbursed. LACC may also need to tell your insurance plan about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.



3. Health Care Operations- In order for LACC to operate in accordance with applicable law and insurance requirements and in order for us to continue to provide quality and efficient care, it may be necessary for LACC to compile, use and/or disclose your PHI. For example, LACC may use your PHI in order to evaluate the performance of our personnel in providing care to you.

ADDITIONAL USES AND DISCLOSURES

In addition to using and disclosing your medical information for treatment, payment, and health care operation, LACC is also permitted or required under federal law to use or disclose your PHI without your consent or authorization in these following instances.

1. We are permitted to use or disclose your PHI if we are providing heath care services to you based on the orders of another health care provider.



2. We are permitted to use or disclose your PHI if we provide health services to you as an inmate.



3. We are permitted to use or disclose you PHI if we provide healthcare services to you in an emergency.



4. We are permitted to use or disclose your PHI if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.



5. We are permitted to use or disclose your PHI if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us provide care.

Other than the circumstances described in the preceding five examples, any other use or disclosure of your PHI will only be made with your written authorization.

APPOINTMENT REMINDER

LACC may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, we may call your home and may leave a message on your answering machine or with the individual answering the phone.

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time.

SIGN-IN LOG

LACC maintains a sign-in log for individuals seeking care and treatment in the office. The sign-in log are located in a position where the staff can readily see who is seeking care in the office. This information may be seen by, and is accessible to, others who are seeking care or services at LACC.

YOUR INDIVIDUAL RIGHTS

You have a right to:

1. Revoke your authorization at any time. To request a revocation, you must submit a written request to LACC's Privacy Office. There are two circumstance under which we will not be able to honor your request:



1. If we have already released your health information before we receive your request to revoke your authorization.


2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your PHI if they decide to contest any of your claims.



2. Request restrictions on certain use and/or disclosure of your PHI as provided by law. If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want LACC to disclose your health information, you must submit a written request to the Privacy Officer. LACC is not required to agree to your restrictions.



3. Receive confidential communications regarding your health information by alternative means or at alternative locations. You must make your request in writing to the Privacy Officer. LACC will accommodate all reasonable requests.



4. Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written a written request to LACC's Privacy Officer. LACC can charge you a fee for the cost of copying, mailing or other supplies associated with your request.



5. Amend your PHI as provided by law. To request your amendment, you must submit a request. LACC may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by LACC, if the information is not part of your PHI maintained by LACC, if the information is not part of the information that you would be permitted to copy, and/or the information is accurate and complete. If you disagree with LACC's, you have the right to submit a written statement of disagreement.



6. Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to LACC's Privacy Officer. The request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The accounting will include all disclosures except:



1. Those disclosures required for your treatment, to obtain payment for your services, or to run practice.


2. Those disclosures made to you.


3. Those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved with your care.


4. Those disclosures for national security or intelligent purpose.


5. Those disclosures make to correctional officers or law enforcement officers.



We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.

7. Receive a paper copy of this Privacy Notice from LACC upon request to the Privacy Officer.

OUR LEGAL DUTIES

We are required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing our legal duties and privacy practices with respect to your PHI.

We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement, we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms, the change will apply for all of your PHI in our files.

RE-DISCLOSURE

Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

YOUR RIGHT TO COMPLAIN

You may complain to LACC or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. While you may make an oral complaint any time, written comments should be addressed to LACC's Privacy Officer. We respect your right to file a complaint and will not take any action against you if you file a complaint.

TO CONTACT US

If you would like further information about our privacy policies and practices pleases contact:

Lincolnwood Acupuncture & Chiropractic Center, P.C.
ATT: Paula Oh
4354 W. Touhy Ave. Lincolnwood, IL 60712
(847) 675-9411