NOTICE OF PRIVACY PRACTICES
AND PATIENT RIGHTS
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.
Effective Date: February 7, 2017
We respect patient/client confidentiality and only release confidential information about you in accordance with Illinois and federal law. This notice describes our policies related to the use of the records of your care generated by this Agency.
In order to effectively provide you care, there are times when we will need to share your confidential information with others beyond our Agency. With your written consent, this includes for:
- Treatment. We may use or disclose treatment information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside our Agency that we are consulting with or referring you to.
- Payment. With your written consent, information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes. You have a right to restrict certain disclosures of your protected health information if you pay out of pocket in full for the services provided to you.
- Healthcare Operations. We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.
Information Disclosed Without Your Consent. Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:
- Emergencies. Sufficient information may be shared to address the immediate emergency you are facing.
- Follow Up Appointments/Care. We may be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may send a letter or leave appointment information on your voice mail or leave an email or text message unless you tell us not to.
- As Required by Law. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse. A U.S. Marshall warrant for your arrest supersedes any confidentiality.
- Coroners. We are required to disclose information about the circumstances of your death to a coroner who is investigating it.
- Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. We are also required to share information, if requested with the U.S. Department of Health and Human Services to determine our compliance with federal laws related to health care and to Illinois state agencies that fund our services or for coordination of your care.
- Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.
- Fundraising/Marketing. As a not-for-profit provider of health care services we need assistance in raising money to carry out our mission. We may contact you to seek a donation. You will have the opportunity to opt out of receiving such communication.
You have the following rights under Illinois and federal law.
- Copy of Record. You are entitled to inspect the client record our Agency has generated about you. We may charge you a reasonable fee for copying and mailing your record.
The Fellowship House fee schedule for medical records is as follows:
|First 25 pages||$ 0.99 per page|
|Pages 26-50||$ 0.66 per page|
|Pages 51+||$ 0.33 per page|
|Handling Fee||$26.38 per request|
|Secretary of State Treatment Verification||$50.00|