Patient Privacy Policy
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!
disclosed and how you can get access to this information. Please review it
carefully!
With your consent, the practice is permitted by federal privacy laws to make uses
and disclosures of your health information for purposes of treatment, payment,
and health care operations. Protected health information is (the information we
create and obtain in providing our services to you. Such information may include
documenting your symptoms, examination and test results, diagnoses, treatment,
and applying for future care or treatment, it also includes billing documents for
those services.
and disclosures of your health information for purposes of treatment, payment,
and health care operations. Protected health information is (the information we
create and obtain in providing our services to you. Such information may include
documenting your symptoms, examination and test results, diagnoses, treatment,
and applying for future care or treatment, it also includes billing documents for
those services.
Example of uses of your health information for treatment purposes:
A clinical assistant obtains treatment information about you and records it in a health record.
During the course of your treatment, the doctor determines a need to consult with
another specialist in the area. The doctor will share the information with such
specialist and obtain input.
A clinical assistant obtains treatment information about you and records it in a health record.
During the course of your treatment, the doctor determines a need to consult with
another specialist in the area. The doctor will share the information with such
specialist and obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company, The health
insurance company requests information from us regarding medical care given.
We will provide information to them about you and the care given.
We submit a request for payment to your health insurance company, The health
insurance company requests information from us regarding medical care given.
We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations
We obtain services from our insurers or other business associates such as quality
assessment quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or
other business associates as necessary to obtain these services
We obtain services from our insurers or other business associates such as quality
assessment quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or
other business associates as necessary to obtain these services
Your Health Information Rights
The health record we maintain and billing records are the physical property of the
practice. The information in it, however, belongs to you. You have a right to:
The health record we maintain and billing records are the physical property of the
practice. The information in it, however, belongs to you. You have a right to:
• Request a restriction of certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to
grant the request but we will comply with any request granted;
• Obtain a paper copy of this Notice of Privacy Practices for Protected Health
Information (“Notice”) by making a request at our office;
• Request that you be allowed to inspect and copy your health record and billing record–you may exercise this right by delivering the request in writing to
our office;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require
that the request for amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as required to
be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment,
or operations, disclosures made to you or made at your request, of disclosures
made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alternative means or at all alternative location by delivering the request in writing to
our office; and,
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office
grant the request but we will comply with any request granted;
• Obtain a paper copy of this Notice of Privacy Practices for Protected Health
Information (“Notice”) by making a request at our office;
• Request that you be allowed to inspect and copy your health record and billing record–you may exercise this right by delivering the request in writing to
our office;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require
that the request for amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as required to
be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment,
or operations, disclosures made to you or made at your request, of disclosures
made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alternative means or at all alternative location by delivering the request in writing to
our office; and,
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office
If you want to exercise any of the above rights, please contact Mrs. Fran Ehrman,
in person or in writing, during normal hours. She will provide you with assistance
on the steps to take to exercise your rights.
in person or in writing, during normal hours. She will provide you with assistance
on the steps to take to exercise your rights.
We reserve the right to amend, change, or eliminate provisions in out privacy
practices and access practices and to enact new provisions regarding the protected
health information we maintain. If our information practices change, we will amend
our Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our “Notice” or by visiting our office and picking up a copy.
practices and access practices and to enact new provisions regarding the protected
health information we maintain. If our information practices change, we will amend
our Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our “Notice” or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S.
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S.
Department of Health and Human Services, Office for Civil Rights (OCR).
• Practice Privacy Officer: Contact our front office staff or call either practice location.
• U.S. Dept. of HHS — OCR: www.hhs.gov/ocr/privacy/hipaa/complaints | 1-800-368-1019 (TDD:
1-800-537-7697)
• Illinois Attorney General — Consumer Protection Division: 1-800-386-543
• U.S. Dept. of HHS — OCR: www.hhs.gov/ocr/privacy/hipaa/complaints | 1-800-368-1019 (TDD:
1-800-537-7697)
• Illinois Attorney General — Consumer Protection Division: 1-800-386-543
• We cannot, and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving treatment
from the practice.
Secretary of Health and Human Services (HHS) as a condition of receiving treatment
from the practice.
• We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Other Disclosures and Uses
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to notify, or assist
in notifying, a family member, personal representative, or other person responsible for your
care, about your location, and about your general condition, or your death.
Communication with Family
in notifying, a family member, personal representative, or other person responsible for your
care, about your location, and about your general condition, or your death.
Communication with Family
Using our best judgement, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information relevant to that person’s
involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
personal friend, or any other person you identify, health information relevant to that person’s
involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse
events with respect to products and product defects, or post-marketing surveillance
information to enable product recalls, repairs, or replacements.
events with respect to products and product defects, or post-marketing surveillance
information to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose
your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
If you are seeking compensation through Workers Compensation, we may disclose
your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to public health or
legal authorities charged with preventing or controlling disease, injury, or disability.
As required by law, we may disclose your protected health information to public health or
legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed
by law to report abuse or neglect.
We may disclose your protected health information to public authorities as allowed
by law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution,
or its agents, your protected health information necessary for your health and the
health and safety of other individuals.
If you are an inmate of a correctional institution, we may disclose to the institution,
or its agents, your protected health information necessary for your health and the
health and safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases involving felony
prosecutions, or to the extent an individual is in the custody of law enforcement.
We may disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases involving felony
prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate
health oversight agencies or for health oversight activities.
Federal law allows us to release your protected health information to appropriate
health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your consent, or as
directed by a proper court order,
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your consent, or as
directed by a proper court order,
Other Uses
Other uses and disclosures besides those identified in this Notice will be made only
as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
Other uses and disclosures besides those identified in this Notice will be made only
as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
Website
If we maintain a website that provides information about our entity, this Notice will
be on the website.
Effective Date: September 14, 2026
If we maintain a website that provides information about our entity, this Notice will
be on the website.
Effective Date: September 14, 2026
Notice of Privacy Practices for Personal Health Information
I, ____________________________________, hereby acknowledge that I have received a copy of this practice’s Notice
of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.
_______________________________________________ _____________________________________________
Name Date
I, ____________________________________, hereby acknowledge that I have received a copy of this practice’s Notice
of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.
_______________________________________________ _____________________________________________
Name Date
