HIPAA Notice of Privacy Practices

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HIPAA Notice of Privacy Practices

Revised January 2020


If you have any questions about this notice or if you need more information, please contact the compliance officer.

About this Notice

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. We are dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices with respect to protected health information. This notice applies to all of the records of your care generated by the Practice. If the Practice revises the terms of this notice, it will post a revised notice in this office and will make paper copies of this Notice of Privacy Practices for Protected Health Information available upon request.

What is Protected Health Information?

Protected Health Information is information that individually identifies you and that we create or get from you or from another health care provider, a health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your healthcare.

How We May Use and Disclose Your Protected Health Information

Your PHI may be used and disclosed by our physicians, office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to obtain payment for services provided to you and to support the operation of our practice.

The following are examples of the types of uses and disclosures of your PHI that our office is permitted to make under HIPAA. These examples are not meant to be exhaustive, but describe some of the types of uses and disclosures that may be made by our office for treatment, payment and health care operations.

For Treatment: We may use PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, we may disclose PHI to doctors, nurses, technicians, or other personnel who are involved in taking care of you, including physicians or health care providers outside our practice, such as referring or specialist physicians or laboratories.

For Payment: Your PHI will be used, as needed, to obtain payment for your health care services from you, your family members or your health insurance provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities.

For Health Care Operations: We may use and disclose PHI for our health care operations. For example, we may use PHI for our general business management activities, for checking on the performance of our staff in caring for you, for our cost-management activities, for audits, or to get legal services. We may give PHI to other health care entities for their health care operations, for example, to your health insurer for its quality review purposes.

All disclosures of your PHI will be limited to the minimum necessary or that which is contained in a limited data set (e.g. PHI that excludes certain identifiers including demographic information, photographs, etc.). We will not sell your PHI without specific, individual authorization.

  • The Practice may also use and/or disclose your medical information in accordance with federal and state laws for the following purposes:
  • To contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
  • When required by the U.S. Department of Health and Human Services as part of an investigation or determination of compliance by the Practice with relevant laws.
  • Unless you object, the Practice may disclose to family members, or other relatives, or close personal friends the medical information directly relevant to such person’s involvement with your care. The Practice may also give relevant information to an individual who helps pay for your care.
  • To public or private entity for the purpose of coordinating with that entity to assist in disaster relief efforts.
  • For public health activities, including the reporting of disease, injury, vital events, and the conduct of public health surveillance, investigation and /or intervention, or to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, and administrative and/or legal proceedings.
  • If you are involved in a lawsuit, claim, potential claim, or dispute, we may disclose medical information about you to attorneys, investigators, insurance companies, and related entities representing the interests of or insuring the doctors and/or other personnel affiliated with the Practice. We may also disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
  • For federal, state, or local law enforcement purposes, or other specialized governmental functions, as follows: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct at this facility; and 6) in emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.
  • To a coroner, medical examiner, or funeral director.
  • To an organ donation and procurement organization if you are an organ donor.
  • For certain research purposes, if the project has been reviewed and approved through a process which balances the research needs with patient privacy interests. We will ask for your consent to participate in any research study, when applicable.
  • To prevent or lessen a serious threat to the health or safety of another person or the public. Any disclosure, however, would only be to someone able to prevent the threat.
  • As authorized by laws relating to workers’ compensation or similar programs.
  • As required by domestic or foreign military command authorities, if you are a member of the armed forces of the United States or a foreign country.
  • As authorized by laws relating to intelligence, counterintelligence, and other national security activities.
  • To authorized federal officials for the protection of the President, or other authorized persons, or foreign heads of state, or to conduct special investigations.
  • To obtain payment for health care services that we provide you. This may include disclosures to your health insurance plan, and disclosures to third parties with respect to payment to such party.

We are required to retain our records of health care services we provide you. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Your Rights Regarding Your Medical Information

You have the following right regarding medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy PHI that may be used to make decisions about your care or payment for your care. Any request for PHI must be made in writing. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request in certain limited circumstances and will provide you a written explanation for that denial. We will also let you know if the reasons for the denial can be reviewed and how to request such a review. Under federal law, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding and other protected information access to which is restricted by law.

Right to an Electronic Copy of Electronic Medical Records: If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Amend. If you feel that medical 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 for as long as the information is kept by or for the Practice. To request an amendment, your request must be made in writing and submitted to this office. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support a request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the Practice; or
  • Is not part of the information which you would be permitted to inspect and copy.

Right to an Accounting of Disclosures. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Right to Request Restrictions. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may deny your request if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to your request unless a law requires us to share that information.

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 alternative communications, you must make your request in writing to this office. We will not ask you the reason for the 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, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You can get a copy of this Notice at our website: https://www.usaveinclinics.com/


If you believe your privacy rights have been violated, you may file a complaint with this Practice and/or the Secretary of the Department of Health and Human Services. To file a complaint with this Practice, please contact our Privacy Officer at (847) 257-1237 or you can mail your complaint to: 304 Wainwright Drive, Northbrook, IL 60062
You will not be penalized for filing a complaint.

This notice is effective as of April 14, 2003

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