YOUR RIGHTS

While your health record is the physical property of Springfield Clinic, the information contained in your health record ultimately belongs to you.

You have the right to:

• To receive a copy of the Springfield Clinic’s Notice of Privacy Practices.
  
• To review your medical records and receive copies of the same.
  
• To request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can request that we contact you only at work or by mail. You will be notified if your request is denied.
  
• To request a restriction or limitation on the medical information we use or disclose for the purpose of treatment, payment or health care operations. You also have the right to request a limit on medical information we disclose about you to someone who is involved in your care, such as a family member or friend.
  
• To request amendments in the medical record according to established Clinic Policy and if the request for amendment is denied, to submit a written statement of the areas you feel are incorrect for inclusion in the medical record.
  
• To expect any amendments made to the medical record will be disseminated to anyone who received the original information.
  
• To request an accounting of disclosures of your health information that Clinic personnel have made in the six (6) years prior to the request date, or during the period between the request date and April 14, 2003, whichever is more recent. Such an accounting will not include disclosures made by Clinic personnel to carry out treatment, payment or health care operations; to ensure national security; to comply with the authorized requests of law enforcement; or to inform you of the content of your medical records. Any accounting also will not include disclosures that you expressly authorize. The first accounting that you request within any 12-month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
  
• To revoke an Authorization to Release Information, except to the extent that action has already been taken in reliance of your authorization.
  
• To register a complaint about any areas where you feel there was a deviation from these rights to the Director of Quality Assessment at the Springfield Clinic and to expect a response from the Director of Quality Assessment addressing your complaint.
  
• To address your complaint to the Administrator of the Springfield Clinic, if the Director of Quality Assessment did not adequately address your concerns.
  
• To address your complaint to the Secretary of Health and Human Services of the United States, if you feel the Springfield Clinic has not adequately addressed your concerns.

The Springfield Clinic places the highest priority on protecting its patient’s medical information. We believe patients should be made aware of the uses of this information within the Clinic and of any disclosures of this information by the Clinic. For any use or disclosure of patient information other than those listed here, a specific authorization signed by the patient, the patient’s parent or guardian or the patient’s designee is required.

OUR RESPONSIBILITIES

To maintain the privacy of your health information.

To provide you with this notice of our legal duties and privacy practices concerning your personally identifiable health information.

To follow the terms of the notice of privacy practices that we have in effect at the time.

To notify you if we are unable to agree to a requested restriction or amendment.

To accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

The terms of this notice apply to all records containing your identifiable health information that are created and maintained by Springfield Clinic.

We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records Springfield Clinic has created or maintained in the past, and for any records we may create and maintain in the future. Springfield Clinic will provide a copy of our current privacy practices on the Springfield Clinic web site [www.SpringfieldClinic.com], posted in public areas of clinic locations and at the time of consent.

For Further information or to report a Problem

Should you have further questions, wish to request restrictions regarding certain disclosures described in this Privacy Notice, or to make a change to your health information, please contact the Director of Medical Records at 217-528-7541.

If you believe your privacy rights have been violated, you can file a complaint with Director of Quality Assessment, at 217-528-7541 or with the secretary of Health and Human Services. Springfield Clinic will not take any retaliatory action for filing a complaint.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION

The following categories describe different ways that we use and disclose your medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in any category is listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

We will use and disclose your health information for treatment.

We will disclose your medical information to you as a patient and to your health care providers, such as physicians, nurses and support staff involved in your treatment, such that they may provide care; to nurses conducting screening for eligibility in research projects; to employees in the physician’s offices and who provide ancillary services. We also will disclose your medical information to residents and students who perform duties at Springfield Clinic, to the extent your medical information is required to perform these duties. We will disclose your medical information to employees in the medical records and transcription areas and their designees. Such that they may provide medical care management. We will also disclose your medical information to pharmacies for the purpose of filling your prescriptions, and to other service providers outside the Clinic for diagnostic purposes. We will also disclose your health information to your family members or friends who are involved in your care.

Notwithstanding the above, we will comply with the requirements of those Illinois laws that limit the use and disclosure of certain health information even with regard to treatment activities. For example, we will not use or disclose any information regarding your HIV or AIDs status, mental health or developmental disabilities information, or genetic testing results without your express authorization, except as otherwise permitted by those laws regulating the use and disclosure of such information.

We will use and disclose your health information for payment.

We will disclose your health information to those family members who are helping you pay for your health care, consistent with Springfield Clinic’s Billing Policy, maintained by Patient Accounting. We will disclose your health information to employees in Patient Accounting such that they may bill you or your health plan for the treatment you receive, and to assist you in receiving reimbursement from your plan. We will also disclose your health information to such third party payers as necessary to obtain payment for your treatment. This may include employers or their designees for on-the-job injuries. As necessary, we will disclose your health information to collection agencies working with Springfield Clinic. We will disclose your medical information to those treatment providers outside the Clinic who are involved in your care, such that they may be paid for their services rendered.

We will use and disclose your health information for regular health care operations.
The Springfield Clinic is committed to providing quality care. For example, we will use your health information to review and assess the quality of care provided; to obtain the input of prudent professionals when developing policies and procedures; to address problems; and for investigation and communication with insurers, attorneys and other relevant parties in regard to problems and incidents. These may include government agencies that perform inspections or investigations within the Clinic, and contracted insurers who also conduct quality reviews for their insured. As an ethical business, Springfield Clinic also makes your health information available for internal review and consultations regarding its business practices, accounts receivable management, information system testing and development, and problem resolution. As an employer who values fair treatment of our employees, the Springfield Clinic maintains and reports medical information for our employees regarding on-the-job injuries and family medical leaves. This information is disclosed to the insurer for coverage purposes.

We will disclose your health information to our contractors.

We will disclose your health information to our “Business Associates” – those vendors with whom we contract to provide a service to the Clinic. Examples of such vendors include the copy service we may use when making copies of your health record, attorneys, auditors, certain health care providers and other agencies. When services are contracted, we may disclose your health information to our vendors such that they can perform the job we have asked them to do, and to bill for their services. To protect your health information, however, we require these vendors to appropriately safeguard your information by requiring that they enter into an appropriate agreement with the Clinic.

We may use your health information to notify you of items of interest.

We may use your medical information to contact you to provide you with appointment reminders or to inform you of potential treatment options or alternatives and to inform you of health related benefits or services that may be of interest to you. Appointment reminders will be left with family members or on phone message machines.

We will disclose your health information as required by law and regulations.

For example, we may disclose your health information to the FDA relative to adverse events with food or drugs. We will disclose your health information to the extent authorized by and necessary to comply with laws relating to workers compensation and similar programs established by law. We may disclose your health information to public health authorities or legal authorities charged with preventing or controlling disease, injury or disability. We may disclose information for law enforcement purposes as required by law or in response to a valid subpoena.

Further, consistent with federal law, we may use or disclose your health information to an appropriate health oversight agency, public health authority or attorney, provided that a member of the Clinic’s workforce believes in good faith that the Clinic has engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

We may use and disclose your health information for research.

Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its uses of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to employees in our Research Department, who are preparing to conduct a research project, for example, to help them look for patients with specific medical needs.

We may use and disclose your health information to avert a serious threat to health or safety.

We may disclose your health information when necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person. Any disclosure, however, would be only to someone able to help prevent or avert the threat.

We may use and disclose your health information in the following special situations:

• Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities.
  
• Public Health Risks. We may release your health information for public health activities while State or Federal Laws require it. A few examples of such activities are disease control, child abuse or neglect, and reactions to medications or problems with products.
  
• Protective Services for the President, National Security and Intelligence Activities. We may release your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counter intelligence and other national security activities authorized by law.
  
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official as necessary (1) for the institution to provide you with care; (2) to protect your health and safety or the health or safety of others; or (3) for the safety or security of the correctional institution.

Effective Date: January 17, 2003