Women's Health Practice

HIPAA Notice of Privacy Practices

Effective Date: April 14, 2003
Revised: November 01, 2004

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 Privacy Officer at Women's Health Practice/Midwest Surgical Center.

NOTE: The "Appointment" page cannot be accessed unless these terms are accepted.

PROVISION OF NOTICE:
Women’s Health Practice/Midwest Surgical Center provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. This Notice is provided no later than the date of the first treatment to the patient after April 13, 2003.

Women’s Health Practice/Midwest Surgical Center makes its Notice available to any member of the public to enable prospective patients to evaluate Women’s Health Practice/Midwest Surgical Center privacy practices when making her decision regarding whether to seek treatment from Women’s Health Practice/Midwest Surgical Center. Women’s Health Practice/Midwest Surgical Center provides its Notice via e-mail to any patient or other individual who so requests the notices.

DOCUMENTATION OF PROVISION OF NOTICE:
When you receive the Notice from Women’s Health Practice/Midwest Surgical Center, Women’s Health Practice/Midwest Surgical Center asks you to sign its “Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices Form”. If you refuse to sign the form, it is noted in your medical record that you were given the Notice and refused to sign the form.

OUR OBLIGATIONS:
We are required by law to:
• Maintain the privacy of protected health information.
• Give you this notice of our legal duties and privacy practices regarding health information about you.
• Follow the terms of our notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
Described as follows are the ways we may use and disclose health information that identifies you (“Health Information”). Except for the following purposes, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to the Women’s Health Practice/Midwest Surgical Center Privacy Officer.

Women’s Health Practice/Midwest Surgical Center does not condition your treatment on the signing of an authorization, except disclosure necessary to determine payment of claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for purpose of creating protected health information for disclosure to a third party (e.g., pre-employment or life insurance physicals).

Treatment. We may use and disclose Health Information for your treatment and to provide you with treatmentrelated health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment.

Health Care Operations. We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you and to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Disclosure to Those Involved in Individual’s Care: Women’s Health Practice/Midwest Surgical Center discloses protected health information to those involved in your care only when you approve or not able to approve, when such disclosure is deemed appropriate in the professional judgment of Women’s Health Practice/Midwest Surgical Center. Women’s Health Practice/Midwest Surgical Center does not disclose protected health information to a suspected abuser, if, in its professional judgment, there is reason to believe that such disclosure could cause you serious harm. Further, Women’s Health Practice/Midwest Surgical Center uses and discloses information as required by law.

Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process.

Women’s Health Practice does conduct Clinical Research. If you decide to participate in a Study, you will sign an informed consent and possibly a separate HIPAA consent. Women’s Health Practice will collect information regarding your participation in the study and release that information to the Sponsor. Employees from the Sponsor may come to check the information obtained by Women’s Health Practice. The FDA may also come to check information.

SPECIAL SITUATIONS:
As Required by Law. We will disclose Health Information when required to do so by international, federal, state, or local law.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

YOUR RIGHTS:
Women’s Health Practice/Midwest Surgical Center never requires an individual to waive her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law. You have the following rights regarding Health Information we have about you:

Right to Inspect and Obtain a Copy. You have a right to inspect and obtain a copy of Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and obtain a copy of this Health Information, you must make your request, in writing, to the Privacy Officer at Women’s Health Practice/Midwest Surgical Center.

Right to Request Amendment: If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to the Privacy Officer at Women’s Health Practice/Midwest Surgical Center.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations, or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the Privacy Officer at Women’s Health Practice/Midwest Surgical Center.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Privacy Officer at Women’s Health Practice/Midwest Surgical Center. Women’s Health Practice/Midwest Surgical Center accepts all requests for restrictions of disclosures of protected health information. Women’s Health Practice/Midwest Surgical Center does not agree to any restrictions in the use or disclosure of protected health information.

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 this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.womenshealthpractice.com. To obtain a paper copy of this notice, contact the Privacy Officer at Women’s Health Practice/Midwest Surgical Center.

CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

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.

Complaints to Women’s Health Practice/Midwest Surgical Center must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of Women’s Health Practice/Midwest Surgical Center Privacy Officer at Women’s Health Practice/Midwest Surgical Center address (2125 South Neil Street, Champaign, Illinois 61820). Women’s Health Practice/Midwest Surgical Center investigates each complaint and may, at its discretion, replay to the patient or the patient’s agent.

Complaints to the Secretary of the Department of Health and Human Services must be in writing, must name Women’s Health Practice/Midwest Surgical Center, must describe the acts or omissions that are the subject of the complaints, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to: Office for Civil Rights, U.S. Department of Health and Human Services, 233 North Michigan Avenue, Suite 204, Chicago, Illinois 60601, Voice phone: (312) 886-2359, FAX: (312) 886-1807, TDD: (312) 353-5693.

Women’s Health Practice /Midwest Surgical Center does not take any adverse action against any patient who files a complaint (either directly or through an agent) against Women’s Health Practice/Midwest Surgical Center.

__________________________

Suzanne Trupin, MD, FACOG

Women's Health Practice

2125 South Neil Street, Champaign, IL 61820

PHONE (217)356-3736
FAX (217) 356-5849