Privacy Notice

Our practice is dedicated to maintaining the privacy of your protected health information. (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentially of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Sherri Leach, Practice Manager, Suburban Surgical Care Specialists/Kane Center- 847-255-9697.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION: Our practice reasonably ensures that the protected health information (PHI) it requests, uses and discloses for any purpose is the minimum amount of PHI necessary for that purpose.

Our practice treats all qualified individuals as personal representatives of our patients. Our practice generally allows individuals to act as personal representatives of patients. The two general exceptions to allowing individuals to act as personal representatives relate to unemancipated minors and abuse, neglect, or endangerment situations.

Our practice makes reasonable efforts to ensure that protected health information is only used by and disclosed to individuals that have a right to the protected health information. Toward that end, our practice makes reasonable efforts to verify the identity of those using or receiving protected health information.

USES AND DISCLOSURES: TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

Our practice uses and discloses protected health information for payment, treatment, and health care operations. Treatment includes those activities related to providing services to the patient, including releasing information to other health care providers involved in the patient’s care. Payment relates to all activities associated with getting reimbursed for services provides, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. Health care operations include a number of areas, including quality assurance and peer review activities.

DISCLOSURES REQUIRED BY LAW: Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

Public Health Risks: Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of: 1) reporting child abuse or neglect 2) maintaining vital records, such as births and deaths, 3) preventing or controlling disease, injury, or disability, 4) notifying a person regarding potential exposure to a communicable disease, 5) notifying a person regarding a potential risk for spreading or contracting a disease or condition, 6) reporting reactions to drugs or problems with products or devices, 7) notifying individuals if a product or device they may be using has been recalled, 8 ) notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information, and 9) notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Uses and Disclosures for Health Oversight Activities: Our practice uses and discloses PHI as required by law for health oversight activities. The information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but not limited to hospital peer review, managed care peer review, or Medicaid or Medicare peer review.

Disclosure for Judicial and Administrative Proceedings: In general, our practice discloses information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order of an ordered administrative tribunal.

Disclosures for Law Enforcement Purposes: Our practice discloses PHI for law enforcement purposes to law enforcement officials.

Serious Threats to Health or Safety: Our practice uses and discloses PHI to public health and other authorities as required by law to avert a serious threat to health or safety.

Specialized Government Functions: Our practice uses and discloses HI for military and veterans activities, national security and intelligence activities, and other activities as required by law.

Emergency Situations: Our practice uses and discloses PHI as appropriate to provide treatment in emergency situations.

Marketing Purposes: Our practice does not use or disclose any PHI for marketing purposes. Our practice does engage in communications about products and services that encourages recipients of the communication to purchase or use the product or service for treatment, to direct or recommend alternative treatments, therapies, health care providers, or setting of care to the individual. These activities are not considered marketing.

INDIVIDUAL RIGHTS

Accounting of Disclosures: Our practice tracks all disclosures of a patient’s PHI that occur for other than the purposes of treatment, payment and health care operations, that are not made to the individual or to a person involved in the patient’s care, that are not made as a result of a patient authorization, and that are not made for national security or intelligence purposes or to correctional institutions or law enforcement officials.

Our practice allows you to request an accounting within a 12-month period free of charge. Our practice charges a reasonable fee for more frequent requests. You can request an accounting of disclosures for a period of up to six years prior to the date of this request. Requests for shorter accounting periods will be accepted. However, patients may only request an accounting of disclosures made on or after April 14, 2003. In order to obtain an accounting of disclosures, you must submit your request in writing to our practice.

Inspect and Copy Protected Health Information: You have the right to inspect and obtain a copy of your PHI, but not including psychotherapy notes. You must submit your request in writing. Our practice will determine the appropriate charge for providing the requested records and inform the requestor in advance of providing the records.

Request Amendment to Protected Health Information: You may ask us to amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. Your request for an amendment must be made in writing to our practice. You must provide us with a reason that supports your request for the amendment. We may deny your request if you ask us to amend information that is in our opinion: 1) accurate and complete, 2) not part of the PHI kept by or for our practice, 3) not part of the PHI which you would be permitted to inspect and copy, or 4) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Request Confidential Communications: You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. In order to request a type of confidential communication, you must make a written request to our practice. No reason for the request needs to be stated. Our practice will accommodate reasonable requests.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Sherri Leach, Practice Manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

• James M. Kane, M.S., M.D., F.A.C.S.
• Peter C. Rantis, Jr., M.D., F.A.C.S.
• Jonathon W. Wallace, M.D.

• James M. Kane, Jr., M.D., F.A.C.S.
• Paul J. Guske, M.D., F.A.C.S.

We realize that these laws are complicated, but must provide you with the following important information:

• How we may use and disclose your PHI.
• Your privacy rights in your PHI.
• Our obligations concerning the use and disclosure of your PHI.