(A) General provisions.
(1) The department or the village's patients have the right to, and the department or the village may not deny, the following:
(a) Access to their own information, consistent with certain limitations;
(b) Receive an accounting of disclosures the department or the village has made of their protected health information (PHI) for up to six years prior to the date of requesting such accounting. Information may not be available prior to the effective date of this policy (April 14, 2003) and certain limitations do apply as outlined in § 12 of this policy; and
(c) Submit complaints if they believe or suspect that information about them has been improperly used or disclosed, or if they have concerns about the privacy policies of the department or the village.
(2) Patients may ask the department or the village to take specific actions regarding the use and disclosure of their information and the department or the village may either approve or deny the request. Specifically, patients have the right to request:
(a) That the department or the village restrict uses and disclosures of their individual information while carrying out treatment, payment activities, or health care operations;
(b) To receive information from the department or the village by alternative means, such as mail, e-mail, fax or telephone, or at alternative locations; and
(c) That the department or the village amend their information that is held by the department or the village.
(B) Relationship to notice of privacy practices.
(1) The department or the village will use the "Notice of Privacy Practices" included within this section to inform patients about how the department or the village may use and/or disclose their information. The "Notice of Privacy Practices" also describes the actions a patient may take, or request the department or the village to take, with regard to the use and/or disclosure of their information.
(2) Nothing in this policy shall prevent the department or the village from changing its policies or the "Notice of Privacy Practices" at any time, provided that the changes in the policies or the "Notice of Privacy Practices" comply with state or federal law.
(C) Decision-making authority within the department or the village.
(1) Prior to any decision, based on a patient's request for the department or the village to amend a health or medical record, the department or the village shall review the request and any related documentation.
(2) Prior to any decision to amend any other information that is not a health or medical record, the department or the village shall review the request and any related documentation.
(3) The department or the village may deny a patient access to his or her own health information on the grounds that access may result in risk or harm to the patient or to another person. However, prior to any decision to deny such access, the department or the village shall review the request and any related documentation.
(4) Decisions related to any other requests made to the department or the village under this policy shall be handled in a manner consistent with federal and state rules and regulations and/or department or village policies and procedures applicable to the treatment, program, service or activity.
(D) Rights of patients to request privacy protection of their information.
(1) Patients have the right to request restrictions on the use and/or disclosure of their information.
(2) The department or the village applies confidentiality laws to protect the privacy of patient information. Even if those laws would permit the department or the village to make a use or disclosure of information, a patient has the right to request a restriction on a use or disclosure of that information.
(3) All requests will be submitted by completing a "Restriction of Use and Disclosures Request Form" included within this section.
(4) The department or the village is not obligated to agree to a restriction and may deny the request or may agree to a restriction more limited than what the patient requested.
(5) Exception: certain programs can only use information that is authorized by the patient, such as alcohol and drug programs or vocational rehabilitation participants. For those program participants, the department or the village will honor their requests for restriction by making sure that the authorization clearly identifies the authorized recipients of the information.
(E) Rights of patients to request to receive information by alternative means or at alternative locations.
(1) The department or the village must accommodate reasonable requests by patients to receive communications by alternative means, such as by mail, e-mail, fax or telephone; and the department or the village must accommodate reasonable requests by patients to receive communications at an alternative location.
(2) In some cases, sensitive health information or health services must be handled with strict confidentiality under state law. For example, information about substance abuse treatment, mental health treatment, and certain sexually transmitted diseases, may be subject to specific handling. The department or the village will comply with the more restrictive requirements.
(F) Rights of patients to access their information.
(1) Patients have the right to access, inspect, and obtain a copy of information on their own cases in the department or the village files or records, consistent with federal and state law.
(2) All requests for access will be made having the patient complete an "Access to Records Request Form" included within this section.
(3) Patients may request access to their own information that is kept by the department or the village by using a personal identifier (such as the patient's name or the department or the village case number).
(4) If the department or the village maintains information about the patient in a record that includes information about other people, the patient is only authorized to see information about him or herself, with the following exceptions:
(a) If a person identified in the file is a minor child of the patient, and the patient is authorized under state law to have access to the minor's information or to act on behalf of the minor for making decisions about the minor's care, the patient may also obtain information about the minor.
(b) If the person requesting information is recognized under state law as a guardian or legal custodian of the patient and is authorized by state law to have access to the patient's information or to act on behalf of the patient for making decisions about the patient's services or care, the department or the village will release information to the requestor.
(c) Any other exceptions or restrictions as may be required under state law.
(5) The department or the village may deny patients' access to their own health information if federal law prohibits the disclosure. Under federal law, patients have the right to access, inspect, and obtain a copy of health information on their own cases in the department or the village files or records except for:
(a) Psychotherapy notes;
(b) Information compiled for use in civil, criminal, or administrative proceedings;
(c) Information that is subject to the Federal Clinical Labs Improvement Amendments of 1988, or exempt pursuant to 42 CFR 493.3(a)(2);
(d) Information that, in good faith, the department or the village believes can cause harm to the patient, participant or to any other person;
(e) Documents protected by attorney work-product privilege; and
(f) Information where release is prohibited by state or federal laws.
(6) Before the department or the village denies a patient access to their information because there is a good faith belief that its disclosure could cause harm to the patient or to another person, the department or the village must make a review of this denial available to the patient. If the patient wishes to have this denial reviewed, the review must be done by a licensed health care professional other than the department or the village as selected by the department or the village.
(G) Rights of patients to request amendments to their information.
(1) Patients have the right to request that the department or the village amend their information in the department or the village's files.
(2) All requests for amendments will be made by having the patient complete an "Amendment of Health Record Request Form" included within this section.
(3) The department or the village is not obligated to agree to an amendment and may deny the requests or limit its agreement to amend.
(H) Rights of patients to an accounting of disclosures of protected health information.
(1) Patients have the right to receive an accounting of disclosures of protected health information (PHI) that the department or the village has made for any period of time, not to exceed six years, preceding the date of requesting the accounting.
(2) The accounting will only include health information not previously authorized by the patient for use or disclosure, and will not include information collected, used or disclosed for treatment, payment or health care operations for that patient.
(3) All requests for an accounting of disclosures will be made by having the patient complete an "Accounting of Disclosures of Protected Health information Form" included within this section.
(4) This right does not apply to disclosures made prior to the effective date of this policy, which is April 14, 2003.
(I) Rights of patients to file complaints regarding disclosure of information.
(1) Patients have a right to submit a complaint if they believe that the department or the village has improperly used or disclosed their protected information, or if they have concerns about the privacy policies of the department or the village or concerns about the department or the village's compliance with such policies.
(2) Complaints may be filed with any of the following:
(a) The Department of Human Services in the State of Illinois or the department or the village.
(b) The U.S. Department of Health and Human Services, Office for Civil Rights.
(J) Requesting restrictions of uses and disclosures.
(1) Patients may request, in writing, and in such form prescribed from time to time by the department or the village, that the department or the village restrict use and/or disclosure of their information for:
(a) Carrying out treatment, payment, or health care operations;
(b) Disclosure of health information to a relative or other person who is involved in the patient's care.
(2) The department or the village is not required to agree to a restriction requested by the patient.
(3) The department or the village will not agree to restrict uses or disclosures of information if the restriction would adversely affect the quality of the patient's care or services.
(4) The department or the village cannot agree to a restriction that would limit or prevent the department or the village from making or obtaining payment for services.
(5) Emergency treatment should be provided even with an agreed upon restriction with exceptions as noted below.
Exception: For alcohol and drug or vocational rehabilitation participants, federal regulations (42 CFR Part 2 and 34 CFR) prohibit the department or the village from denying patient requests for restrictions on uses and disclosures of their information regarding treatment or rehabilitation.
(6) The department or the village will document the patient's request, and the reasons for granting or denying the request in the patient's hard copy or electronic case record file.
(7) Prior to any use of disclosure of patient information, the department or the village staff must confirm that such use or disclosure has not been granted a restriction by reviewing the patient's case file. If the department or the village agrees to a patient's request for restriction, the department or the village will not use or disclose information that violates the restriction.
Exception: If the patient needs emergency treatment and the restricted information is needed to provide emergency treatment, the department or the village may use or disclose such information to the extent needed to provide the emergency treatment. However, once the emergency situation subsides the department or the village must not redisclose the information.
(8) The department or the village may terminate its agreement to a restriction if:
(a) The patient agrees to or requests termination of the restriction in writing;
(b) The patient orally agrees to, or requests termination of the restriction. The department or the village will document the oral agreement or request in the patient's case record file; or
(c) The department or the village informs the patient in writing that the department or the village is terminating its agreement to the restriction. Information created or received while the restriction was in effect shall remain subject to the restriction.
(K) Requesting alternative means or locations.
(1) The patient must specify the preferred alternative means or location.
(2) Requests for alternative means or alternative locations for information may be made orally or in writing.
(3) If a patient makes a request orally, the department or the village will document the request and ask for the patient's signature.
(4) If a patient makes a request by telephone or electronically, the department or the village will document the request and verify the identity of the requestor.
(5) Prior to any information being sent to the patient, the department or the village staff must confirm if the patient has requested an alternate location or by alternate means, and if the department or the village has granted that request, by reviewing the patient's case file.
(6) The department or the village may terminate its agreement to an alternative location or method of communication if:
(a) The patient agrees to or requests termination of the alternative location or method of communication in writing or orally. The department or the village will document the oral agreement or request in the patient's department or the village case record file.
(b) The department or the village informs the patient that the department or the village is terminating its agreement to the alternative location or method of communication because the alternative location or method of communication is not effective. The department or the village may terminate its agreement to communicate at the alternate location or by the alternative means if:
1. The department or the village is unable to contact the patient at the location or in the manner requested; or
2. If the patient fails to respond to payment requests if applicable.
(1) Requesting access to information.
(1) The department or the village will assure that patients may access their information that the department or the village uses in whole or part to make decisions about them, subject to certain limitations as outlined in § 6 of this policy.
(2) Patients may request to access, inspect and obtain information about themselves, subject to limitations as outlined in this policy.
(3) All requests for access will be made by having the patient complete an "Access to Records Request Form" included within this section.
(4) The department or the village may deny a patient access to their information if:
(a) It is excepted under § 6 of this policy; or
(b) Was obtained from someone other than a health care provider under a promise of confidentiality, and access would reveal the source of the information.
(5) The department or the village may deny a patient access to their information, provided that the department or the village gives the patient a right to have the denial reviewed, in the following circumstances:
(a) The department or the village has determined, in the exercise of professional judgment, that the information requested may endanger the life or physical safety of the patient or another person;
(b) The protected information makes reference to another person, and the department or the village has determined, in the exercise of professional judgment, that the information requested may cause substantial harm to the patient or another person; or
(c) The request for access is made by the patient's personal representative, the department or the village has determined, in the exercise of professional judgment, that allowing the personal representative to access the information may cause substantial harm to the patient or to another person.
(6) If the department or the village denies access, the patient has the right to have the decision reviewed by a licensed health care professional not directly involved in the department or the village's original denial decision. The department or the village will then proceed based on the decision from this review.
(7) The department or the village must promptly refer a request for review to the designated reviewer.
(8) The reviewer must determine, within a reasonable time, whether or not to approve or deny the patient's request for access, in accordance with this policy.
(9) The department or the village must then:
(a) Promptly notify the patient in writing of the reviewer's determination; and
(b) Take action to carry out the reviewer's determination.
(10) The department or the village must act on a patient's request for access no later than 30 days after receiving the request.
(11) In cases where the information is not maintained or accessible to the department or the village on-site, the department or the village must act on the patient's request no later than 60 days after receiving the request.
(12) If the department or the village is unable to act within these 30-day or 60-day limits, the department or the village may extend this limitation by up to an additional 30 days, subject to the following:
(a) The department or the village must notify the patient in writing of the reasons for the delay and the date by which the department or the village will act on the request.
(b) The department or the village will use only one such 30-day extension to act on a request for access.
(13) If the department or the village grants the patient's request, in whole or in part, the department or the village must inform the patient of the access decision and provide the requested access.
(14) If the department or the village maintains the same information in more than one format (such as electronically and in a hard-copy file) or at more than one location, the department or the village need only provide the requested protected information once.
(15) The department or the village must provide the requested information in a form or format requested by the patient, if readily producible in that form or format. If not readily producible, the department or the village will provide the information in a readable hardcopy format or such other format as agreed to by the department or the village and the patient.
(16) If the department or the village does not maintain, in whole or in part, the requested information, and knows where the information is maintained, the department or the village will inform the patient of where to request access.
(17) The department or the village may provide the patient with a summary of the requested information, in lieu of providing access, or may provide an explanation of the information if access had been provided, if:
(a) The patient agrees in advance; and
(b) The patient agrees in advance to any fees the department or the village may impose, and as allowed by law and/or described below.
(18) The department or the village must arrange with the patient for providing the requested access in a time and place convenient for the patient and the department or the village. This may include mailing the information to the patient if the patient so requests or agrees.
(M) Fees for patient information request.
(1) A patient (or legal guardian or custodian) may request a copy of their information at no cost once every 12 months. If the patient requests a copy of the requested information, or a written summary or explanation, more frequently than once every 12 months, then the department or the village may impose a reasonable, cost-based fee, limited to covering the following:
(a) Copying the requested information, including the costs of supplies and of the labor of copying;
(b) Postage, when the patient has requested or agreed to having the information mailed; and
(c) Preparing an explanation or summary of the requested information, if agreed to in advance by the patient, per § 6 of this policy.
(2) If the department or the village denies access, in whole or in part, to the requested information, the department or the village must:
(a) Give the patient access to any other requested patient information, after excluding the information to which access is denied;
(b) Provide the patient with a timely written denial. The denial must:
1. Be sent or provided within the time limits specified in § 6 of this policy;
2. State the basis for the denial, in plain language;
3. If the reason for the denial is due to danger to the patient or another, explain the patient's review rights as specified in § 6 of this policy including an explanation of how the patient may exercise these rights; and
4. Provide a description of how the patient may file a complaint with the department or the village, and if the information denied is protected health information, with the United States Department of Health and Human Services (DHHS), Office of Civil Rights, pursuant to § 13 of this policy.
(3) If the department or the village does not maintain the requested protected information, and knows where such information is maintained (such as by a medical provider, insurer, other public agency, private business, or other non-department or village entity), the department or the village must inform the patient of where to direct the request for access.
(N) Requesting amendments of information.
(1) All requests for amendments will be made by having the patient complete an "Amendment of Health Record Request Form" included within this section.
(2) The department or the village will honor requests for alternative methods of making this request if reasonable accommodations are needed.
(3) The department or the village must act on the patient's request no later than 60 days of receiving the request. If the department or the village is unable to act on the request within 60 days, the department or the village may extend this time limit by up to an additional 30 days, subject to the following:
(a) The department or the village must notify the patient in writing of the reasons for the delay and the date by which the department or the village will act on the receipt; and
(b) The department or the village will use only one such 30-day extension.
(4) If the department or the village grants the request, in whole or in part, the department or the village must:
(a) Make the appropriate amendment to the protected information or records, and document the amendment in the patient's file or record;
(b) Provide timely notice to the patient that the amendment has been accepted, pursuant to the time limitations in § 6 of this policy;
(c) Seek the patient's agreement to notify other relevant persons or entities, with whom the department or the village has shared or needs to share the amended information, of the amendment; and
(d) Make reasonable efforts to inform, and to provide the amendment within a reasonable time to:
1. Persons named by the patient as having received protected information and who thus need the amendment; and
2. Persons, including business associates of the department or the village, that the department or the village knows have the protected information that is the subject of the amendment and that may have relied, or could foreseeably rely, on the information to the patient's detriment.
(5) Prior to any decision to amend a health or medical record, the request and any related documentation shall be reviewed by the department or the village.
(6) Prior to any decision to amend any other information that is not a health or medical record, the department or the village shall review the request and any related documentation.
(7) The department or the village may deny the patient's request for amendment if:
(a) The department or the village finds the information to be accurate and complete;
(b) The information was not created by the department or the village, unless the patient provides a reasonable basis to believe that the originator of such information is no longer available to act on the requested amendment;
(c) The information is not part of the department or the village records; or
(d) If it would not be available for inspection or access by the patient, as specified in § 6 of this policy.
(8) If the department or the village denies the requested amendment, in whole or in part, the department or the village must:
(a) Provide the patient with a timely written denial. The denial must:
1. Be sent or provided within the time limits as specified in this policy above;
2. State the basis for the denial, in plain language;
3. Explain the patient's right to submit a written statement disagreeing with the denial and how to file such a statement. If the patient does so:
a. The department or the village will enter the written statement into the patient's department or village case file;
b. The department or the village may also enter a department or village written rebuttal of the patient's written statement into the patient's department or village case record. The department or the village will send or provide a copy of any such written rebuttal to the patient;
c. The department or the village will include a copy of that statement, and of the written rebuttal by the department or the village if any, with any future disclosures of the relevant information;
d. Explain that if the patient does not submit a written statement of disagreement, the patient may ask that if the department or the village makes any future disclosures of the relevant information, the department or the village will also include a copy of the patient's original request for amendment and a copy of the department or the village written denial; and
e. Provide information on how the patient may file a complaint with the department or the village, or with the U.S. Department of Health and Human Services (DHHS), Office of Civil Rights, subject to provisions in § 13 of this policy.
(O) Requesting an accounting of disclosures.
(1) When a patient requests an accounting of disclosures that the department or the village has made of their protected health information, the department or the village must provide that patient with a written accounting of such disclosures made during the six-year period (or lesser time period if specified by the requesting patient) preceding the date of the patient's request.
(2) All requests for an accounting of disclosures will be made by having the patient complete an "Accounting of Disclosures Request" included within this section.
(3) Examples of disclosures of protected health information (PHI) that are required to be listed in an accounting (assuming that the disclosure is permitted by other confidentiality laws applicable to the individual's information and the purpose for which it was collected or maintained) include:
(a) Abuse report: PHI about an individual provided by the department or the village staff pursuant to mandatory abuse reporting laws to an entity authorized by law to receive the abuse report.
(b) Audit review: PHI provided by the department or the village staff from an individual's record in relation to an audit or review (whether financial or quality of care or other audit or review) of a provider or contractor.
(c) Health and safety: PHI about an individual provided by the department or the village staff to avert a serious threat to health or safety of a person.
(d) Licensee/provider: PHI provided by the department or the village from an individual's records in relation to licensing or regulation or certification of a provider or licensee or entity involved in the care or services of the individual.
(e) Legal proceeding: PHI about an individual that is ordered to be disclosed pursuant to a court order in a court case or other legal proceeding. A copy of the court order must be included with the accounting.
(f) Law enforcement official/court order: PHI about an individual provided to a law enforcement official pursuant to a court order. A copy of the court order must be included with the accounting.
(g) Law enforcement official/ deceased: PHI provided to law enforcement officials or medical examiner about a person who has died for the purpose of identifying the deceased person, determining cause of death, or as otherwise authorized by law.
(h) Law enforcement official/ warrant: PHI provided to a law enforcement official in relation to a fleeing felon or for whom a warrant for their arrest has been issued and the law enforcement official has made proper request for the information, to the extent otherwise permitted by law.
(i) Media: PHI provided to the media (TV, newspaper, etc.) that is not within the scope of an authorization by the individual.
(j) Public health official: PHI about an individual provided by the department or the village staff (other than staff employed for public health functions) to a public health official, such as the reporting of disease, injury, or the conduct of a public health study or investigation.
(k) Public record: PHI about an individual that is disclosed pursuant to a public record request without the individual's authorization.
(l) Research: PHI about an individual provided by the department or the village staff for purposes of research conducted without authorization, using a waiver of authorization approved by an IRB - a copy of the research protocol should be kept with the accounting, along with the other information required under the HIPAA privacy rule, 45 CFR 164.528(b)(4).
(4) Disclosures that are not required to be tracked and accounted for are those that are:
(a) Authorized by the patient;
(b) Made prior to the original effective date of this policy, which is April 14, 2003;
(c) Made to carry out treatment, payment, and health care operations;
(d) Made to the patient;
(e) Made to persons involved in the patient's health care;
(f) Made as part of a limited data set in accordance with § 9 of this policy;
(g) For national security or intelligence purposes; or
(h) Made to correctional institutions or law enforcement officials having lawful custody of an inmate.
(5) The accounting must include, for each disclosure:
(a) The date of the disclosure;
(b) The name, and address if known, of the person or entity who received the disclosed information;
(c) A brief description of the information disclosed; and
(d) A brief statement of the purpose of the disclosure that reasonably informs the patient of the basis for the disclosure, or, in lieu of such statement, a copy of the patient's written request for a disclosure, if any.
(6) If, during the time period covered by the accounting, the department or the village has made multiple disclosures to the same person or entity for the same purpose, or as a result of a single written authorization by the patient, the department or the village may provide:
(a) Although the department or the village must provide a written accounting for disclosures made over a six year period, only the first disclosure made during the time period is necessary (the department or the village need not list the same identical information for each subsequent disclosure to the same person or entity) if the department or the village adds;
(b) The frequency or number of disclosures made to the same person or entity; and
(c) The last date of the disclosure made during the requested time period.
(7) The department or the village must act on the patient's request for an accounting no later than 60 days after receiving the request, subject to the following:
(a) If unable to provide the accounting within 60 days after receiving the request, the department or the village may extend this requirement by another 30 days. The department or the village must provide the patient with a written statement of the reasons for the delay within the original 60-day limit, and inform the patient of the date by which the department or the village will provide the accounting.
(b) The department or the village will use only one such 30-day extension.
(P) Fees for patient accounting requests.
(1) The department or the village must provide the first requested accounting in any 12-month period without charge. The department or the village may charge the patient a reasonable cost-based fee for each additional accounting requested by the patient within the 12-month period following the first request, provided that the department or the village:
(a) Informs the patient of the fee before proceeding with any such additional request; and
(b) Allows the patient an opportunity to withdraw or modify the request in order to avoid or reduce the fee.
(2) The department or the village must document, and retain in the patient's department or village case record file, the information required to be included in an accounting of disclosures, as set forth in this policy, and send a copy of the written accounting provided to the patient.
(3) The department or the village will temporarily suspend a patient's right to receive an accounting of disclosures that the department or the village has made to a health oversight agency or to a law enforcement official, for a length of time specified by such agency or official, if:
(a) The agency or official provides a written statement to the department or the village that such an accounting would be reasonably likely to impede their activities.
(b) However, if such agency or official makes an oral request, the department or the village will:
1. Document the oral request, including the identity of the agency or official making the request;
2. Temporarily suspend the patient's right to an accounting of disclosures pursuant to the request; and
3. Limit the temporary suspension to no longer than 30 days from the date of the oral request, unless the agency or official submits a written request specifying a longer time period.
(Q) Filing a complaint.
(1) Patients may file complaints with the department or the village's Privacy Officer, and/or with the department or the village's State Department of Human Services and/or with the U.S. Department of Health and Human Services (DHHS), the Office for Civil Rights. The department or the village must give patients the specific person or office and address of where to submit complaints. The complaint process is more fully set forth hereinafter in this policy.
(a) Contact information for the department or the village's State Department of Human Services:
Address:
Phone:
Fax:
(b) Contact information for the U.S. Department of Health and Human Services, Office for Civil Rights:
Medical Privacy, Complaint Division
200 Independence Avenue, SW
Washington, D.C. 20201
Toll free phone: 877-696-6775
Phone: 866-627-7748
TTY: 886-788-4989
E-mail: www.hhs.gov/ocr
(2) The department's Privacy Officer is responsible for enforcing this policy, and shall be entitled to the assistance of the Village Manager in doing so, if such assistance should be needed. Individuals who violate this policy will be subject to the appropriate and applicable disciplinary process under this policy and the applicable ordinances of the village, up to and including termination or dismissal.
(R) Forms. The following are the sample forms presently authorized for the uses specified under the terms of this policy.
(1) Department/Village Notice of Privacy Practices.
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.
If you have any questions about this notice, please contact the Romeoville Fire Department Shift Commander on duty at 815-886-7227, 18 Montrose Drive, Romeoville, Illinois 60446.
WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by our employees, staff and other office personnel.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the health care and services you receive at this office. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.
For example, this includes such things as verbal and written information that we obtain about you and use pertaining to your medical condition and treatment provided to you by us and other medical personnel (including doctors and nurses who give orders to allow us to provide treatment to you). It also includes information we give to other health care personnel to whom we transfer your care and treatment, and includes transfer of PHI via radio or telephone to the hospital or dispatch center as well as providing the hospital with a copy of the written record we create in the course of providing you with treatment and transport.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.
For Payment We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.
For Health Care Operations We may use and disclose health information about you in order to run the office and make sure that you and our other patients receive quality care. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
Treatment Alternatives We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
SPECIAL SITUATIONS
We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law We will disclose health information about you when required to do so by federal, state or local law.
Research We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.
Organ and Tissue Donation If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners and Funeral Directors We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Information Not Personally Identifiable We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person's involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Riqht to Inspect and Copy You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to the Romeoville Fire Department Privacy Officer or his designee in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.
To request an amendment, complete and submit a Medical Record Amendment/Correction Form to the Romeoville Fire Department Privacy Officer or his designee. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
a) We did not create, unless the person or entity that created the information is no longer available to make the amendment.
b) Is not part of the health information that we keep.
c) You would not be permitted to inspect and copy.
d) Is accurate and complete.
Riqht to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing to the Romeoville Fire Department Privacy Officer or his designee. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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.
Right to Request Restrictions You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are Not Required to Agree to Your Request If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you may complete and submit the Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication to the Romeoville Fire Department Privacy Officer or his designee. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact the Romeoville Fire Department Privacy Officer or his designee.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Romeoville Fire Department Privacy Officer at 815-886-7227. You will not be penalized for filing a complaint.
(2) Acknowledgment of receipt of notice of privacy practices.
Romeoville Fire Department/Village of Romeoville
Acknowledgment of Receipt of Notice of Privacy Practices
I hereby acknowledge that I have been provided with a copy of ABC Fire District's Notice of Privacy Practices on this date.
Date Signature
PRINT NAME OF PATIENT
Street Address
City, State and Zip Code
(3) Request for restriction on use and disclosure of PHI.
REQUEST FOR RESTRICTION ON USE & DISCLOSURE OF PHI
Patient Name:
Phone Number (Day):
Phone Number (Evening):
Street or PO Box:
City:
State:
Zip:
1) Medical Information to be Restricted:
2) Nature of Restriction:
3) Medical Information to be Communicated Confidentially:
4) Alternative Location/Address/Telephone Number/E-mail:
TO OUR PATIENTS: You have the right to request that we restrict our use and disclosure of your medical records and information. We do not have to agree to your requested restrictions. If we do agree to the requested restriction, we will abide by the restriction unless a medical emergency requires otherwise. You also have the right to request that we communicate certain medical information to you in confidence. We will accommodate your reasonable written requests to receive communications of medical information by alternative means or at alternative locations only if you (1) specify the alternative location, address, or telephone number and/or the alternative means of contact and (2) agree to be responsible for and explain how payment will be handled for any additional costs associated with the alternative method of communication.
By your signature below, you acknowledge that you understand and agree to the above information.
Signature of Patient:
Date:
Request for Restriction Accepted
Request for Restriction Denied
Request to Communicate Confidentiality Accepted
Request to Communicate Confidentiality Denied
This Request for Restriction and Confidential Communication Form is to be made a part of the medical record of: (Patient Name)
(4) Patient request for access form.
Romeoville Fire Department/Village of Romeoville
Patient Request for Access Form
Patient:
Date:
Address:
City: State: Zip Code:
Social Security No.:
Last Date of Service:
Patient Rights: As a patient, you have the right to access, copy or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices and in other policies, which you may have upon request.
To better allow us to process your request, please indicate the type of request you are making on this form: [check all that apply]
Access to simply review my health information.
Access to obtain copies of my health information.
Access to review and potentially request amendment of my health information.
Access to review and potentially request an accounting of how my PHI has been used and disclosed to others.
Access to review and potentially request restrictions on the use and disclosure of my health information.
We will evaluate your request and will either grant it or explain the reason why the request will not be granted. In the event that your inspection request is not granted you may request that the decision be reviewed by someone other than the person who originally denied the request.
Signature Request Date
REVIEW SECTION INTERNAL USE ONLY
This section is to be completed by the reviewer:
Date received: | Reviewed by: |
Chief Privacy Officer: | Review Date: |
The inspection request is hereby:
Granted
Denied
If the request is denied, indicate the reason for the denial:
Reviewer's Comments:
(5) PHI/Medical Record Amendment/Correction Form.
MEDICAL RECORD AMENDMENT/CORRECTION FORM
Patient Name:
Phone Number (day):
Phone Number (night):
Street or PO Box:
City:
State:
Zip:
1) Date of Medical Record Entry to be Corrected:
2) Medical Record Language to be Amended/Corrected:
3) Amendment/Correction:
4) Reason for the Amendment/Correction:
5) Identify persons who have received the Information (prior to Amendment/Correction):
Name Organization/Address Phone Number
6) Do you authorize us to provide the information in Items no. 3 and no. 4 to the persons and organizations listed in Item no. 5?
Yes
No, do not provide the information to:
TO OUR PATIENTS: You have the right to submit a Medical Record Amendment/Correction Form to be made a part of your medical record. This right does not permit you to alter or change the original record created by your health care provider or his/her staff. We may deny your request to amend or correct your records.
Amendment/Correction Accepted:
Amendment/Correction Denied:
Reason for Denial:
This Amendment/Correction Sheet Is to Be Made a Part of the Medical Record of:
Patient Name:
Date:
Signature of Patient:
If we have denied your requested amendment/correction, you have the right to submit a written statement disagreeing with the denial and your reason for disagreement. We may reasonably limit the length of your written statement, and we may prepare a rebuttal to your written statement of disagreement (and provide you with a copy).
If we have denied your requested amendment/correction and you do not submit a written statement of disagreement as discussed above, you may request that we include a copy of this document with any future disclosures of the information identified in Items # 1 and # 2 above.
Please make your request in writing, and sign and date the request.
If you believe we have failed to meet our obligations as explained in our "Notice Of Privacy Practices" or our legal obligations under state or federal law, you may contact the Romeoville Fire Department Privacy Officer at 815-886-7227, 18 Montrose Drive, Romeoville, Illinois, 60446 regarding your complaint. You may also file a complaint with Secretary of the U.S. Department of Health and Human Services within 180 days of the date you know or should know of the act that is the subject of your complaint. Your complaint to the Secretary must be filed in writing, either electronically or on paper.
(6) Request for accounting of disclosures of PHI.
Request for Accounting of Disclosures of
Protected Health Information
ROMEOVILLE FIRE DEPARTMENT/VILLAGE OF ROMEOVILLE
18 MONTROSE DRIVE, ROMEOVILLE, ILLINOIS 60446
815-886-7227
As required by the Health Information Portability and Accountability Act of 1996 you have a right to request an accounting of disclosures of health information that pertains to you.
REQUEST SECTION
I, (Patient name) hereby request an accounting of disclosures of my protected health information that have occurred over the last (Time Period - Up to 6 years).
Signature ` Date
REQUEST PROCESSING SECTION - INTERNAL USE ONLY
This section is to be completed by the reviewer:
Date received: | Reviewed by: |
Chief Privacy Officer: | Review Date: |
The requested disclosure accounting was processed on (Date).
(7) Denial of request for access to PHI.
Romeoville Fire Department/Village of Romeoville
Denial of Request for Access to Protected Health Information
Dear [INSERT REQUESTOR'S NAME]:
We have carefully reviewed your request to have access to certain protected health information (PHI) that the Romeoville Fire Department has in its possession about you. Unfortunately, we are unable to grant your request for access to this information.
The basis for this denial is that:
1. The information you requested was compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding;
2. The information you requested was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of information.
The denials for reasons #1 and #2 are final and you may not appeal the decision to deny access to the information.
3. A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonable likely to endanger the life or physical safety of the individual or another person;
4. The protected health information makes reference to another person (other than a health care provider) and a licensed health professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to that person;
5. The request for access is made by you as a personal representative of the individual about whom you are requesting the information, and a licensed health professional has determined, in the exercise of professional judgment, that access by you is reasonably likely to cause harm to the individual or another person.
Denials for access for reasons #3, #4 or #5 may be reviewed in accordance with the review procedure described below.
Review Procedures
If the denial of your request for access to PHI is for reasons #3, 4 or 5, you may request a review of the denial of access by sending a written request to:
Romeoville Fire Department Privacy Officer, 18 Montrose Drive, Romeoville, Illinois 60446
We will designate a licensed health professional, who was not directly involved in the denial, to review the decision to deny you access. We will promptly refer your request to this designated review official. The review official will determine within a reasonable period of time whether the denial is appropriate. We will provide you with written notice of the determination of the designated review official.
You may also file a complaint in accordance with our enclosed complaint procedures (available upon request) if you are not satisfied with our determination.
Sincerely,
Privacy Officer
Romeoville Fire Department
(Ord. 0030-03, passed 4-2-03)