The following is a summary of the NOTICE OF PRIVACY PRACTICES, which you will receive a copy of. 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 privacy notice applies to the individuals and organizations providing you service at the office of Stacie D. McClane, M.D., Chicago Plastic Surgery Center, LLC, 680 North lake Shore Drive, Suite 1425, Chicago, IL 60611. Some of the individuals or organizations providing you care and services at Chicago Plastic Surgery Center, LLC may also provide care at other locations and/or facilities. This notice only applies to individuals and entities providing care at Chicago Plastic Surgery Center, LLC. Other privacy practices may apply at different locations.

We are required by law to maintain the privacy of your medical information. We must provide you with a copy of this notice. We must follow the terms of this notice. If the notice changed in any material way, a revised notice will be available upon request. We will use your medical information for Treatment. For example, a member of our staff who is providing your care will report any changes in your condition to your Doctor. We will use your medical information for Payment. For example, we may need to give your insurance company information about your diagnosis, treatment and the supplies used. We will use your medical information for Health Care Operations. For example, we may use your medical information to evaluate our services. We may contact you at any phone number, mail or e-mail address you have provided to us to remind you of an appointment or other health care matters or to obtain payment for our services.

We may use and disclose your medical information to inform you of treatment alternatives or other health related benefits and services. We may disclose your medical information to family members or others who are involved in your care or payment for that care. You must notify our Privacy Officer in writing if you do not want us to communicate with you in any of these ways. We may use your medical information for any uses that are required or permitted by law. Other uses and disclosures will be made only with your written authorization. You may cancel an authorization at any time by notifying our Privacy Officer in writing.

You have the following rights: Right to privacy notice; Right to request restrictions on uses and disclosures of your medical information; Right to inspect and copy your medical information; Right to request an amendment to your medical information; and a Right to an accounting of disclosures of your medical information.

Contact Information. If you feel that your privacy rights have been violated, please contact our Privacy Officer at 312-867-9500 or the Secretary of Health and Human Services. As indicated by my signature below I acknowledge I have read this summary of the Notice of Privacy Practices.



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Signature of Patient or Personal Representative                  Date

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Printed name of patient

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Printed Name of Personal Representative and description of Personal Representative’s authority to act on Patients behalf.

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 IMFORMATION. PLEASE READ 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.

This privacy notice applies to the individuals and organizations providing you service at Chicago Plastic Surgery Center, LLC at 680 North Lake Shore Drive, Suite 1425 Chicago, IL 60611. Some of the individuals or organizations providing you care and services at Chicago Plastic Surgery Center, LLC also provide care at other locations and /or facilities. This notice only applies to individuals and entities providing care at Chicago Plastic Surgery Center, LLC. Other privacy practices may apply at different locations.

We are required by law to maintain the privacy of your medical information. We must give you a copy of this notice and get your signature that you have received it. We must follow the terms of this notice that are currently in effect. If we must revise this notice, copy of the revised notice will be available upon request, posted at our location, and 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 you first received treatment from Chicago Plastic Surgery Center, LLC. In an emergency, we will give you notice as soon as possible after the emergency treatment has been given

 

(PLEASE RETAIN THIS COPY FOR YOUR RECORDS)


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. For example, we may report your medical condition to your primary care physician. 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 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.

Common Disclosures for Treatment, Payment or Health Care Operations

We may contact you by telephone, by facsimile, by mail or by e-mail at your home or your office to remind you of an appointment you have with us or anything else about the health care services we provide or payment for your health care services. We may leave messages for you. If you want us to contact you in a certain way or at a certain location, see “Right to Receive Confidential Communications” in this notice. 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 have a written contract with them that requires that they protect the privacy of your medical information.

Other Uses and Disclosures of Your Medical Information

Treatment Alternatives-We may use and disclose medical information about you to tell you about other health care treatment available to you. If you do not want to receive these communications, please notify our Privacy Officer in writing.

Health Related Benefits and Services-We may use and disclose medical information about you to tell you about other health care benefits or services that may interest you. If you do not want to receive these communications, please notify our Privacy Officer in writing.

Individuals Involved in Your Care-We may disclose medical information about you to a family member, other relative, close friend or other person identified by you if they are involved in your care or payments related to your care. We may 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 to about you, please notify our Privacy Officer in writing.

Use or Disclosures That Are Required or Permitted by Law

Disaster Relief- We may use or disclose medical information about you to assist in disaster relief efforts. This will be done to notify family members or others of your location, general condition or death in case of a natural or man-made disaster.

Required by Law-We may use or disclose medical information about you when the law requires us to do so.

Communicable Diseases-We may disclose your medical information to a person who may have been exposed to an infectious disease or who is at risk of spreading the disease or condition.

Public Health Activities- We may disclose medical information about you for public health activities to prevent or control disease.

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, in response to a subpoena or other legal process.

Disclosures for Law Enforcement Purposes- We may disclose medical 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.
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 Disclosure That Require Your Authorization

Other uses and disclosures will be made only with your written authorization. You may cancel your authorization at any time by notifying our Privacy Officer in writing of your desire to cancel. If you cancel an authorization it will not have any affect on information that we have already disclosed. Some examples of uses or disclosures that may require your written authorization are:

  • A request to provide your medical information to an attorney for use in a civil law suit.
  • The use of photographs taken of you for medical education purposes.

Your Rights

The information contained in your health or medical record is the physical property of Chicago Plastic Surgery Center, LLC. 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 our Privacy Officer. 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 Chicago Plastic Surgery Center, LLC 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 way or at a certain place. If you want to request confidential communications the request must be made in writing to our Privacy Officer. We must agree to your request if it is reasonable.

Right to Inspect and Copy Your Medical Information-You have the right to ask to inspect and obtain a copy of your medical information. You must submit your request in writing to our Privacy Officer. If you request a copy of the information or we provide you with a summary of the information we may charge a fee for the cost 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 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 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 our Privacy Officer.

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 Disclosure of Health Information-You have the right to find out what disclosures of your medical information have been. 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 cannot include disclosures made before April 14, 2003.

We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. Requests for accounting of disclosures must be submitted in writing to our Privacy officer. 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 & Human Services if you believe we have violated your privacy rights. There is no risk involved if you file a complaint.

To file a complaint with us contact us in writing:

Dr. McClane
Chicago Plastic Surgery Center, LLC
680 N. Lake Shore Dr.
Suite 1425
Chicago, IL 60611
Phone:312-867-9500
Fax: 312-674-7501

To file a complaint with the United States Secretary of Health and Human Services send your complaint in writing to:

Office of Civil Rights, Region V
U.S. Department of Health & Human Services
233 N. Michigan Avenue
Suite 240
Chicago, Il 60611
Phone: 312-886-2359
Fax: 312-886-1807
TDD: 312-353-5693

Questions & Information

If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer:

Office Manager
Chicago Plastic Surgery Center, LLC
680 N. Lake Shore Dr.
Suite 1425
Chicago, IL 60611
Phone: 312-867-9500
Fax: 312-674-7501

Contact us by mail with written requests for information as defined under the YOUR RIGHTS section of this notice.

The current effective date of this Privacy Notice is: April 14, 2003

This notice was revised on: 12/19/06