How Little Company of Mary may use or disclose your health information
This notice is to inform you that the following entities shall operate as one single affiliated covered entity for HIPAA purposes only, and shall be collectively referred to as Little Company of Mary, herein after referred to as: LCM:
- Little Company of Mary Hospital and Health Care Centers (2800 W. 95th St., Evergreen Park, IL 60805)
- LCM Home Based Services / Hospice (9800 S. Southwest Highway, Oak Lawn, IL 60453)
- LCM Mobile Medical and its Physicians (9800 S. Southwest Highway, Oak Lawn, IL 60453)
Ambulatory Outpatient Facilities
- Mary Potter Physicians Pavilion (2850 W. 95th St., Evergreen Park, IL 60805)
- LCM Diagnostic Center (12432 S. Harlem, Palos Heights, IL 60463)
- LCM Halsted Medical Center (736 West 95th St., Chicago, IL 60628)
- LCM Oak Lawn Care Station (5660 W. 95th St., Oak Lawn, IL 60453)
- LCM Burbank Medical Center (4901 W. 79th St., Burbank, IL 60459)
- LCM Outpatient Care Center (6700 W. 95th St., Oak Lawn, IL 60453)
Little Company of Mary Affiliated Services, Inc.
- LCM Affiliated Physicians [Mary Potter] (2850 W. 95th St., Evergreen Park, IL 60805)
- LCM Affiliated Physicians [Palos] (12450 S. Harlem, Palos Heights, IL 60463)
- LCM Affiliated Physicians [Halsted] (736 West 95th St., Chicago, IL 60628)
- LCM Affiliated Physicians [Care Station] (5660 W. 95th St., Oak Lawn, IL 60453)
- LCM Affiliated Physicians [Burbank] (4901 W. 79th St., Burbank, IL 60459)
- LCM Affiliated Physicians [Vista] (10961 S. Kedzie, Chicago, IL 60655)
- LCM MSO Billing Office (2800 W. 87th St., Chicago, IL 60652)
And all other LCM affiliated locations as they become available
The use of a Joint Notice and Acknowledgement Form, as part of an OHCA, is being done only for patient convenience and to improve access to the delivery of health care services. The physician(s) providing services through the aforementioned OHCA are independent contractors and not agents of Little Company of Mary and are solely responsible for their judgment and conduct in providing treatment and for their compliance with state and federal law.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE READ IT CAREFULLY.
How Little Company Of Mary May Use Or Disclose Your Health Information
Federal law requires Little Company of Mary to maintain the privacy of individually identifiable, protected health information (PHI) and to provide you with notice of its legal duties and privacy practices with respect to such information. Little Company of Mary must abide by the terms and conditions of this Privacy Notice, and Little Company of Mary may revise this Privacy Notice.
A. Uses Or Disclosures of Health Information for Treatment, Payment & Health Care Operations
Little Company of Mary may use your individually identifiable health information for treatment, payment and health care operations. Examples of treatment, payment and health care operations include:
"Treatment" includes sharing your information with any provider who is providing you with health services. This includes coordinating your care with other providers and providing referrals to other provders. The type of health information that Little Company of Mary could use or disclose includes, but is not limited to, such health conditions as blood type, diagnosis of your condition or pregnancy status. Little Company of Mary may use or disclose your individually identifiable health information for its own provision of treatment or may disclose such information for the treatment activities of another health care provider.
"Payment" includes Little Company of Mary's efforts to obtai reimbursement from you or a responsible third party for services that Little Company of Mary has provided to you. Little Company of Mary may use or disclose your individually identifiable information for its own payment or for the payment and activities of another health care provider or health plan or health care clearinghouse, or another party. We will submit a bill that identifies you, your diagnosis and the treatment provided.
"Health care operations" includes using your medical nformation to support and ensure quality health services are being provided to you at Little Company of Mary. Some of the activities which would be part of our operations are quality assessment and improvement activities, employee review, licensure and accreditation, and audits of the process of billing you or a third party for health care services Little Company of Mary provides to you. As part of Little Company of Mary's treatment of you and operation of health care organization, Little Company of Mary may contact you, by phone or by mail, to provide appointment reminders or to provide information about treatment alternatives or other health-related services that may be of interest to you. Little Company of Mary may also contact you for fundraising purposes. You have the right to opt out of receiving any fundraising communication received from, or on behalf of, Little Company of Mary. Little Company of Mary may use or disclose your individually identifiable health information for its own health care operation or for limited health care operations of a health plan, health care clearinghouse, or health care provider that is subject to certain federal health information privacy laws. Subject to limited exceptions, the entity which receives this information must have or have had a treatment relationship with you and the information we disclose must pertain to that relationship.
B. Uses or Disclosures Little Company Of Mary May Make Without Your Authorization
In addition to treatment, payment and health care operations, and unless this Privacy Notice recites a more stringent restriction in Section, C, the law permits or requires Little Company of Mary to make, use and/or disclose individually identifiable health information without your written authorization: (1) for certain public health activities and purposes, including reporting of adverse product events to the Food and Drug Administration, (2) to report suspected abuse, neglect or dmestic violence, (3) to assist an organ procurement organization or organ bank in facilitating organ or tissue donation and transplantation, (4) to further research, provided that Little Company of Mary complies with federal requirements, (5) to avert a serious and imminent threat to public health safety, (5)(a) to avert a serious threat to your health or safety or the health and safety of others, (6) for specialized government functions, including activities related to the military, veterans, or national security, (7) to comply with workers' compensation or similar laws. Little Company of Mary will make the above uses and/or disclosures of information in accordance with applicable law. In addition, Little Company of Mary may use and/or disclose your individually identifiable health information as follows:
Business associates: There are some services provided in Little Company of Mary through contracts with usiness associates which are vendors, professionals and others who perform some treatment, payment or health care operations function on behalf of Little Company of Mary or who otherwise provide services and have access to or use your protected health information. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information by requiring that they enter into an appropriate agreement with Little Company of Mary or, in the case of a subcontractor, an appropriate agreement with a business associate of Little Company of Mary.
Directory: Unless you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you are unable to object, we may use and disclose this information consistent with your prior expressed preference, if known, and the health professional's judgement.
Notification: Unless you object, health professionals, using their best judgment, may use or disclose nformation to notify or assist in notifying a family member, personal representative, or any person responsible for your care, your location, and general condition. If you are unable to object, we may exercise our professional judgment to determine if a disclosure is in your best interest and disclose only information that is directly relevant to the person's involvement with your health care.
Individuals involved in your care or payment of your care: Unless you object, health professionals, using their best judgment, may use or disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care. If you are unable to object, we may exercise our professional judgment to determine if disclosure is in your best interest and disclose only information that is directly relevant to the person's involvement with your health care.
Disaster Relief: We may use or disclose information for disaster relief purposes.
Incidental Uses and Disclosures: We are permitted to use and disclose information incident to another use r disclosure of your protected health information permitted or required under law.
- Limited Data Sets: We may use or disclose a limited data set (i.e. in which certain identifying information has been removed) of your protected health information for purposes of research, public health, or health care operations. Any recipient of that limited data set must agree to appropriately safeguard your information.
C. More Stringent Protection For Your Health Information
In certain cases, Illinois law provides more stringent privacy protections of your health information that this Privacy Notice recites above. For example, in some cases, Illinois requires that you provide permission for the use or disclosure of your individually identifiable health information. In those cases, Little Company of Mary must follow the state law even though certain federal health information privacy laws may not require permission. State law provides more stringent protection in the following areas of your PHI subset 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 sexually transmitted disease diagnoses; (6) is about genetic testing; (7) is about child abuse or neglect; (7) is about domestic abuse of an adult with a disability; or (8) is about sexual assault. In order for us to use or disclose your highly confidential information for a purpose other than those required by law, we must obtain your written authorization.
We will need your written authorization to use and disclose your PHI for marketing purposes, except if the marketing is a face-to-face communication or if it involves a promotional gift of nominal value.
E. No Other Uses Or Disclosures Without Your Written Authorization
Little Company of Mary may not make any other uses and disclosures of your individually identifiable health information without your written authorization. In particular, uses and disclosures of your psychotherapy notes, or of your individually identifiable health information for marketing purposes, or uses or disclosures that constitute a sale of your individually identifiable health information, will be made only with your written authorization, unless otherwise permitted or required by law, as described above. You may revoke your authorization at any time if you provide written notice to Little Company of Mary, but only to the extent no action has been taken in reliance on your prior authorization.
F. Your Rights
Federal and state law protect your right to keep your individually identifiable health information private.
Your Right ti Receive Confidential Communications and to Request Restrictions
You may request that you receive communication from Little Company of Mary regarding individually identifiable health information by alternative means or at alternative locations. You must make your request for confidential communications in writing and must submit this request to the office listed below. Little Company of Mary reserves the right to condition your request on the receipt of information regarding how you desire Little Company of Mary to handle payment and/or on the availability of an alternative address or method of contact that you may request. You may request other restrictions on certain uses and disclosures of protected health information for purposes of treatment, payment, and health care operations; however, the law does not require Little Company of Mary to agree to the requested restrictions unless one of two scenarios exist. First, Little Company of Mary must agree to a restriction request that is a reasonable restriction on communication. Second, Little Company of Mary must comply with your request to restrict disclosure of your individually identifiable information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the information pertains solely to a health care item or service for which you, or any person other than the health plan on your behalf, has paid Little Company of Mary in full.
Your Right to Inspect and Copy
You generally have the right ti inspect and obtain a copy of any protected health information in your medical record, with the exception of psychotherapy notes, information compiled in anticipation of use in a civil, criminal, or administrative proceeding and certain other health information which the law restricts Little Company of Mary from disseminating. However, if you are a patient of certain types of providers or facilities, you may have a right to access your patient records or information on an unqualified basis. Specifically, the following:
- If you are a patient at a facility that performs mammograms, you have the right to access your original ammograms and copies of your patient reports on an unqualified basis.
- If you are a patient of a naprapath, acupuncturist or hospital, you have the right to access your patient ecords on an unqualified basis, upon written request.
- If you are a patient of a physician, you have the right to access your medical data on an unqualified basis upon request.
- If you are a recipient of mental health or developmental disabilities services and if you are age 12 or older, you have an unqualified right to inspect and copy your records. The following persons also have this right: (1) your guardian if you are age 18 or older; (2) an appointed agent under a power of attorney for health care which authorizes record access; (3) your parent or guardian if you are under age 12; (4) your parent or guardian if you are, at least, age 12 but under 18 and if certain conditions are satisfied; and (5) a guardian d litem representing you in any judicial or administrative proceeding if you are age 12 or older.
Request for Records
To see and obtain copies of your medical information, you must sign an Authorization for Release of Information form. This form is available for hospital records from the Medical Records Department. For physician records, the form is available from the physician's office. There may be a fee for the costs of copying and providing the copies and other expenses associated with complying with your requests as allowed by state law. We may deny your request to see and/or obtain copies of medical information in very limited circumstances. If that event occurs, you will be given an explanation. Your medical records are the physical property of Little Company of Mary or your physician. Original records will not be given to you or to anyone on your behalf.
Your Right to Amend
You also have the right to amend your individually identifiable health information, unless Little Company of Mary did not create such information or unless Little Company of Mary determines that your medical record is accurate and complete in its existing form.
Your Right to An Accounting
You have the right to request and receive an accounting of disclosures of your individually identifiable health information that Little Company of Mary has made in either the six (6) years prior to the request date, but no earlier in time than 04/14/03, the date that federal law required Little Company of Mary to comply with federal privacy regulations, whichever is more recent. This information is available from the Medical Records Department via Correspondence Request(s). This is a list of the disclosures we made of medical information about you. Such an accounting may not include disclosures made to carry out treatment, payment or health care operations, to create an accurate patient directory or notify persons involved in your care, to ensure national security, to comply with the authorized request of law enforcement, to inform you of the content of your medical records, or those disclosures which you have previously authorized pursuant to a validly
executed authorization form. There may be a charge associated with providing the disclosure; you will be notified of the costs. If you would like more information on how to exercise these rights, please contact Little Company of Mary's Privacy Officer at 708-229-6397 to request the form "Request for Accounting of Disclosures."
Your Right to Breach Notification
You have the right to be notified of a breach of unsecured protected health information that affects you.
G. The Right To Get This Notice By E-Mail
You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via -mail, you also have the right to request a paper copy of this notice
H. Grievances Or Further Inquiries
If you believe that Little Company of Mary has violated your privacy rights with respect to individually identifiable health information, you may file a complaint with Little Company of Mary and the Department of Health and Human Services. To file a complaint with Little Company of Mary, please contact the Privacy Officer at 708-229-6397. Little Company of Mary will not retaliate against you for filing a complaint. You may also contact the above office for a copy of this Privacy Notice or for further information regarding its contents.
Little Company of Mary reserves the right to amend the terms of this Privacy Notice at any time and to apply the revised Privacy Notice to all individually health information that it maintains. If Little Company of Mary amends this Privacy Notice, you will be provided with a revised copy at your next visit to Little Company of Mary, or upon your request. The revised Privacy Notice will also be available on Little Company of Mary's web site, www.lcmh.org.
This Privacy Notice is effective on September 23, 2013.