- A caring atmosphere: We take time to listen and answer your questions fully.
- Educational support: We feel that a well-informed patient is one of our best assets in providing successful treatment and prevention. We provide you with a thorough explanation of your diagnosis and treatment options.
NOTICE OF PRIVACY PRACTICES:
The terms of this notice apply to all records containing your IHI that are created or retained by our practice. We reserve the right to revise or correct this Notice of Privacy Practices.
Any revision or change to this notice will be effective for all of your records that our practice has created or maintained in the past and for any of your records that we may create or
maintain in the future. Our practice will post a copy of our current notice in our office/s in a visible location, and you may request a copy of our most current notice at any time.
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE OF THIS NOTICE:
SEPTEMBER 13th, 2013
ACADEMIC DERMATOLOGY & SKIN CANCER INSTITUTE
50 E. Washington Avenue, Suite 200, Chicago, IL 60602 • Tel #: 312.230.0180
As Required by the Privacy Regulations Created as a Result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. THE INFORMATION
HERE IS REFLECTIVE OF THE HIPAA CHANGES THAT TOOK EFFECT ON MARCH 26th, 2013. PLEASE REVIEW THIS NOTICE CAREFULLY.
OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individual IDENTIFIABLE HEALTH INFORMATION (IHI). In conducting our business, we will create records regarding
you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to
provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IHI. By federal and state law, we must follow the terms of
the notice of privacy practices that we have in effect at the time.
WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IHI) IN THE FOLLOWING WAYS:
Our practice may use and disclose your IHI in order to bill and collect payment for the services
and items you may receive from us. For example, we may contact your health insurer to verify that you are eligible for benefits (and their scope), and we may provide your insurer with details
regarding your treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your IHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IHI to bill you directly for services and
items. We may disclose your IHI to other health care providers and entities to assist in their billing and collection efforts.
II. TREATMENT OPTIONS
We may use and disclose your IHI to inform you of potential treatment options or alternatives.
We will use and disclose your IHI when we are required to do so by federal, state or local law.
Our practice may use your IHI to treat you. For example, we may ask you to have laboratory tests(such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might also disclose your IHI to a pharmacy when we write a prescription for you. Many of the people who work for our practice (including, but not limited to our doctors and nurses) may use or disclose your
IHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IHI to others that take part in managing your care.
V. HEALTH CARE OPERATIONS
Our practice may use and disclose your IHI to operate our business. For example, we may use
your information to evaluate the quality of care you received from us, or to conduct costmanagement
and business planning activities for our practice. We may disclose your IHI to other
health care providers to assist in their health care operations.
VI. APPOINTMENT REMINDERS
Our practice may use and disclose your IHI to contact you and remind you of your appointment.
VII. RELEASE OF INFORMATION TO FAMILY / FRIENDS
Our practice may release your IHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask for a babysitter to take their child to the dermatologist’s office for treatment of a rash. In this example, the babysitter may have access to this child’s medical information.
VII. DISCLOSURES REQUIRED BY LAW
We will use and disclose your IHI when we are required to do so by federal, state, or local law.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE PLEASE CONTACT:
Omeed M. Memar, M.D., Ph.D.
Medical Director, ADSCI • Tel#: 312.230.0180
USE AND DISCLOSURE OF YOUR IHI IN CERTAIN SPECIAL CIRCUMSTANCES:
III. PUBLIC HEALTH RISKS
Our practice may disclose your IHI to public health authorities that are authorized by law to collect information for the purpose of: Maintaining vital records, such as births and deaths / Reporting child abuse or neglect / Preventing or controlling disease, injury or disability / Notifying a personregarding potential exposure to a communicable disease / Reporting reactions to drugs orproblems with products or devices / Notifying individuals if a product or device they may be using has been recalled / Notifying appropriate government agencies and authorities regarding thepotential abuse or neglect of an adult patient (including domestic violence), however, we will onlydisclose this information if the patient agrees or we are required or authorized by law to disclosethis information / Notifying your employer under limited circumstances related primarily to workplace injury, illness or medical surveillance.
II. HEALTH OVERSIGHT ACTIVITIES
Our practice may disclose your IHI to a health oversight agency for activities authorized by law.
Examples of oversight activities can include: investigations, inspections, audits, surveys, licensureand disciplinary actions, as well as civil, administrative, and criminal procedures or actions, or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
I. LAWSUITS AND SIMILAR PROCEEDINGS
Our practice may use and disclose your IHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your IHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but
only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
IV. LAW ENFORCEMENT
We may release IHI if asked to do so by law enforcement official.
YOUR INDIVIDUAL RIGHTS REGARDING YOUR MEDICAL INFORMATION
I. RIGHT TO RECEIVE A COPY OF THIS NOTICE
It is your right to receive the most updated paper copy of this notice even if you have received anelectronic version in the past. You can request a copy of our Notice of Privacy Practices from ourfront desk staff. You can also request to speak to our Privacy Officer if you have any questions.
II. RIGHT TO REQUEST RESTRICTIONS OF THE USE OF YOUR MEDICAL INFORMATION
A request can be made to protect parts or all of your medical records from being disclosed to
particular person or entity. We are not required to agree with your request. If you wish to make a request please do so in writing and indicate a reason for restriction, what to restrict, and from whom.
Additionally, if you are paying for services and/or procedures solely out-of-pocket, you have a right to keep that information confidential from your health plan. We are legally required to comply with your request. Such requests have to be made in writing through a provided form. Our Practice has implemented rules to ensure compliance and privacy of such information.
III. RIGHT TO REQUEST ACCOUNTING OF NON-STANDARD DISCLOSURES
Disclosures of your medical information that are not required by the law or any other regulation to
persons or entities who do not take part in your treatment are tracked by us. To view a list of these disclosures of your medical information you can submit a written request to our Privacy Officer.
Disclosures before January 1st, 2006 are not available. Your request should indicate the time
period for which you want to receive data.
IV. RIGHT TO ACCESS AND COPY YOUR PERSONAL HEALTH INFORMATION
Your personal health information will normally include medical and billing records, but will exclude information compiled for legal proceedings to which access is prohibited by law. You can receive a copy of your medical information by submitting a written request to our Privacy Officer.
V. RIGHT TO AMEND YOUR MEDICAL RECORD
If you believe the medical information we hold about you is incorrect or incomplete you have a right to request a review and possible adjustment to your health record. Such requests have to be made in writing by providing a reason and additional supporting materials for your action. We will deny your request if we have not created the record, and if the entity or person that did create it is still in business or if the record is accurate.
VI. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION
You can request to use other than your regular method of communication to be contacted regarding your treatment. For instance, using only a specific e-mail address instead of the telephone number
given. We must comply with these requests, however if you cannot be reached the regular contact information may be used.
We realize that these laws are complicated, but we must provide you with the following important information:
- Our obligations concerning the use and disclosure of your IHI
- How we may use and disclose your IHI
- Your privacy rights in your IHI
III. HEALTH-RELATED BENEFITS AND SERVICES
We may use and disclose your IHI to inform you of health-related benefits or services that may be of interest to you.
Please provide us with at least 24 hours advance notice for any appointment changes. This will enable us to better accommodate another patient.
CANCELLATION & "NO SHOW" POLICY
Failure to cancel appointments within 24 hours or "no shows" may result in a minimum charge ranging from $75.00 up to the full fee of the procedure.
Prescription refills are handled during office hours when we have full access to your medical records. Refills are not routinely filled on holidays, weekends, or if you have not been seen for more than six months.
FEES, PAYMENT & INSURANCE:
We participate in many insurance plans. Please be certain to provide our office with completed and signed insurance forms, billing information (insurance card) and all required referral and authorization forms prior to, or at the time of each visit.
For our patients who do not carry medical insurance, we do ask for full payment at the time services are rendered by check or credit card. All elective cosmetic procedures must be paid for in advance.