RML SPECIALTY HOSPTIAL
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.
1. Who We Are
This Notice describes the privacy practices of RML Specialty Hospital, its patient care staff, support staff, and other personnel. It applies to services furnished to you at 5601 S. County Line Road, Hinsdale, Illinois 60521 and 3435 W. Van Buren Street, Chicago, Illinois 60624.
2. Our Privacy Obligations
We are required by law to maintain the privacy and security of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). We are required to promptly notify you if a breach occurs that may have compromised the privacy or security of your information
3. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), in order to treat you, obtain payment for services provided to you and conduct our “health care operations”
as detailed below:
- Treatment. We use and disclose your PHI to provide treatment and other services to you–for example, to diagnose and treat your injury or illness. We may also disclose PHI to other providers involved in your treatment.
- Payment. We may use and disclose your PHI to obtain payment for services that we provide to you–for example, disclosures to claim and obtain payment from
your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payer”) to verify that Your Payer
will pay for health care.
- Health Care Operations. We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to an Administrative Representative in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.
We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
B. Use or Disclosure for Directory of Individuals in RML Specialty Hospital. We may include your name, location in RML Specialty Hospital, general health condition, date of admission, admitting service, physician, isolation status, case manager, and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy and isolation status will only be disclosed to visitors who need to be made aware of precautions to protect you and themselves from infection. You may request restrictions on our use and disclosure of the information listed above in our patient directory. While we are not required to agree to a requested restriction, we will do our best to accommodate any reasonable request.
C. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
D. Fundraising Communications. We may contact you to request a tax-deductible contribution to support important activities of RML Specialty Hospital. In connection with any fundraising, we may disclose to our fundraising staff demographic information about you (e.g., your name, address and phone number) and dates on which we provided health care to you, without your written authorization. If you wish to make a tax-deductible contribution now or do not want to receive any fundraising requests in the future, you may contact our Fund Development Office at (630) 286-4400.
E. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
F. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
G. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
H. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
I. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
J. Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.
K. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
L. Research. We may use or disclose your PHI without your consent or authorization if our Institutional Review Board approves a waiver of authorization for disclosure.
M. Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
N. Disaster Relief Situations. You have both the right and the choice to tell us to share information in a disaster relief situation. If you are not able to tell us your preference, we may go ahead and share your information if we believe it is in your best interest.
O. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
P. Workers’ Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with State law relating to workers’ compensation or other similar programs.
Q. As required by law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
4. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
B. Marketing. We must also obtain your written authorization (“Your Marketing Authorization”) prior to using your PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter without obtaining Your Marketing Authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.) In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.
C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (7) is about domestic abuse of an adult with a disability; or (8) is about sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.
5. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact Hospital Administration. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, Hospital Administration will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction and we may say “no” if it would affect your care. If you wish to request additional restrictions, please obtain a request form from our Admitting Office (630-286-4002) and submit the completed form to the Admitting Office. We will send you a written response. 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 with this request unless a law requires us to share that information.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Admitting Office identified below. A form of Written Revocation is available upon request from the Admitting Office.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Health Information Management Department (630-286-4117) and submit the completed form to the Health Information Management Department. If you request copies, we will charge you $.75 per page for pages 1-25, $.50 per page for pages 26-50, $.25 per page for pages 51 and higher, and any shipping costs if you wish the record to be mailed to you. [ILPA92-0228]
F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Health Information Management Department (630-286-4117) and submit the completed form to the Health Information Management Department. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $.75 per page of the accounting statement.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
I. Right to Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
6. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on September 23, 2013.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in the admitting area at RML Specialty Hospital and on our Internet site at mw.cymplersolutions.com. You also may obtain any new notice by contacting the Admitting Office (630-286-4002).
7. Privacy Office
You may contact the Privacy Office at:
RML Specialty Hospital
5601 S. County Line Road
Hinsdale, Illinois 60521
Telephone Number: (630) 286-4458
For more information see: