NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.

We are required by law to give you this Notice of our duties and privacy practices and your rights. We are required to follow the terms of this Notice. This Notice also describes some, but not all of the uses and disclosures we may make with your protected health information. This Notice also describes your rights to access and control your protected health information including demographic information that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. There are other laws that provide additional protections for medical information related to treatment for mental health, alcohol abuse, drug abuse, and HIV/AIDS. We will follow the requirements of those laws for these types of medical information.

WE MAY USE AND DISCLOSE INFORMATION FOR THE FOLLOWING PURPOSES

Treatment: We will use or disclose your protected health information to provide treatment, and to coordinate, or manage your healthcare and any related services. For example, we give information to doctors, nurses, lab technicians, students, and others, including information from tests you receive and we record that information for others to use. We may provide information to your health plan or other providers to arrange for a referral or consultation. The University of Illinois is an Academic Medical Center; therefore, residents, medical students, nursing students and students of other allied health professions may also use or disclose your protected health information.

Payment: We will use or disclose your protected health information, as needed, to obtain payment for your health care services. For example, we may contact your insurer to verify benefits for which you are eligible, obtain prior authorization, and give them details they need about your treatment to make sure they will pay for your care. We will also use or disclose your medical information to bill directly and to obtain payment from third parties that may be responsible for payment, such as family members.

Healthcare Operations: We will use or disclose your protected health information, as needed, in order to perform healthcare operations. Healthcare operations include, but are not limited to: quality assessment/improvement activities; risk management, claims management, legal consultation, physician and employee review activities; licensing; and regulatory surveys. We may also disclose your protected health information to our business associates that perform activities on our behalf, for example, Medicare; and for other business planning activities

Fundraising: We may use and disclose to our Foundation or others, contact information and the dates of your care, but not your treatment information, to contact you as part of a fundraising effort. If you receive a communication from us for fundraising purposes you will be told how you may request not to be contacted in the future.

Directory Information: Unless you object, we will use and disclose in our facility directory – your name, the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation will be disclosed to people that ask for you by name, including the media. We will give your religious affiliation to clergy only, even if they do not ask for you by name. You may tell patient registration to keep your information out of the directory, but you should know that if you do florists and other visitors may not be able to find your room or contact you.

Appointments and Services: We may use and disclose your protected health information to remind you of an appointment, or to give you information about treatment alternatives or other health related benefits or services that may interest you.

Individuals Involved In Your Care/Disaster Relief Organizations: We may disclose your protected health information to a friend or family member who is involved in your care unless you ask us not to. We may disclose information to disaster relief organizations, such as the Red Cross, so that your family can be notified about your condition and location.

With Your Authorization: We may use or disclose your protected health information for purposes not described in this Notice, or otherwise permitted by law, only with your written authorization. You may revoke any authorization at any time, in writing, but only as to future uses or disclosures, and only where we have not already acted in reliance on your authorization.

USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR AUTHORIZATION, CONSENT, OR OPPORTUNITY TO OBJECT

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law, but only to the extent and under the circumstances provided in such law.

Public Health: We may use or disclose your protected health information for public health activities such as reporting births, deaths, communicable diseases, injury or disability, ensuring the safety of drugs and medical devices, reporting child and sexual abuse, and for work place surveillance or work related illness and injury.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight Activities: We may disclose your protected health information to a health oversight agency for activities authorized by law such as audits, administrative or criminal investigations, inspections, licensure or disciplinary action and monitoring compliance with the law.

Abuse, Neglect or Domestic Violence: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe you may be a victim of abuse, neglect or domestic violence to the governmental agency or entity authorized to receive such information. This disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, or to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose your protected health information in response to court or administrative orders, or under certain circumstances in response to subpoenas, discovery requests or other lawful processes.

Law Enforcement: We may disclose your protected health information to identify or locate suspects, fugitives or witnesses, or victims of crime, to report deaths from crime, crimes on the premises, or in emergencies, the commission of a crime.

Coroners, Medical Examiners, Funeral Directors: We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your protected health information to a funeral director in order to permit them to carry out their duties.

Organ Donation: We may disclose your protected health information to organizations that handle organ procurement and/or eye or tissue transplantation.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure your privacy.

National Security: We may disclose your health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President.

Criminal Activity: We may disclose your health information consistent with applicable federal and state laws if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Military Activity: We may disclose your health information if you are in the armed forces and information is required by command authorities, or for the purposes of a determination by the Department of Veteran Affair of your eligibility for benefits.

Correctional Institutions: We may disclose your protected health information if you are an inmate for your health and the health, and safety of others.

Worker’s Compensation: We may disclose your protected health information as authorized to comply with worker’s compensation laws and other similar legally established programs.

YOUR HEALTH INFORMATION RIGHTS

Right to Obtain a Copy of this Notice of Privacy Practices: We will provide you with a copy of the current Notice of Privacy Practices if you request it. A copy of the current Notice in effect will be available at the registration areas of our facilities and it is available upon request. You have the right to obtain a paper copy of this notice upon request, even if you have agreed to accept this notice electronically. It is also available at our web site: http://www.uillinoismedcenter.org.

Right to Request a Restriction on Certain Uses and Disclosures: You have the right to request restrictions on uses and disclosures of your medical information for the purposes of treatment, payment or healthcare operations. We are not required to allow your request. If we do agree with the request, we will comply with your request except to the extent that disclosure has already occurred or if you are in need of emergency treatment and the information is needed to provide the emergency treatment.

Right to Inspect and Request a Copy of your Health Record: You have the right to inspect and obtain a copy of your health record, except in limited circumstances defined by federal regulations. A fee may be charged to copy your record. If you are denied access to your health record for certain reasons the denial may be reviewable. Please contact our Privacy Officer for more information.

Right to Request an Amendment to your Health Record: You may make a written request to amend your protected health information. You must give us a reason for the amendment. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have any questions about amending your health record.

Right to Obtain an Accounting of Disclosures of your Health Information: The accounting will only provide information about disclosures made for purposes other than treatment, payment or healthcare operations; disclosures to you or authorized by you are excluded. You have the right to receive specific information regarding disclosures made only after April 14, 2003. Please contact our Privacy Officer to obtain an Accounting and Disclosure Report.

Right to Request Communication of your Health Information: You have the right to request that confidential communications be made by alternate means (e.g. fax versus mail) or at alternate locations (alternate address or telephone number). Your request must be in writing. We must honor your request if it is reasonable. Please make this request in writing to our Privacy Officer.

Contact: To exercise any of the rights described above, or if you have any questions about this Notice, please contact our Privacy Officer at (312) 355-5650 or mail questions to the University of Illinois Medical Center at Chicago, Health Information Management Department (MC 772), 833 South Wood Street, B52, Chicago, Illinois, 60612-7209, Attention: Privacy Officer. To file a complaint with the Compliance Hotline call 1-866-665-4296. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue. S.W., Room 509F, HHH Building, Washington, D.C. 20201.There will be no retaliation for filing a complaint.

Changes to this Notice: We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facilities and it will also be posted on our web site at http://www.uillinoismedcenter.org.

Effective Date: April 14, 2003