MidAmerica Plastic Surgery: Ryan Diederich, MD
4955 South State Route 159 #1
Glen Carbon, IL 62034
Monday: 7 a.m.–5 p.m.
Tuesday: 8 a.m.–5 p.m.
Wednesday: 7:30 a.m.–5 p.m.
Thursday: 8 a.m.–5 p.m.
Friday: 8 a.m.–12 p.m.
The Spa at MidAmerica Plastic Surgery
4955 South State Route 159 #1
Glen Carbon, IL 62034
Monday – Thursday: 8 a.m.–7 p.m.
Friday: 8 a.m.–4 p.m.
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.
Who Will Follow This Notice:
This Notice will be followed by Southwestern Illinois Health Facilities, Inc., d/b/a Anderson Hospital (“Anderson Hospital”), Maryville Imaging, LLC, Maryville Physicians’ Services, LLC, and Maryville Medical Services, LLC, which together form an affiliated covered entity under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and HIPAA privacy rules. This Notice will also be followed by independent medical staff members and medical groups while providing services at, or on behalf of, one of these affiliated entities. When this Notice refers to “we,” “us,” and “our,” it is referring to this group of providers and affiliated entities who have formed relationships authorized by HIPAA which permit us to use or disclose your Protected Health Information amongst ourselves to carry out treatment, payment and health care operations and for other purposes permitted or required by law.1 “Protected Health Information” includes all paper and electronic records pertaining to your health care and payment for your health care.
Our Pledge Regarding Protected Health Information:
We understand that your Protected Health Information is personal and we are committed to protecting privacy of such information. This Notice will tell you about the ways in which we may use or disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes our obligations and your rights regarding the use and disclosure of your Protected Health Information.
I. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION
Unless otherwise prohibited by law, we may use and disclose your Protected Health Information as described below without obtaining an authorization from you (or your personal representative). We explain below each category of use or disclosure, but we do not list every use or disclosure in a category.
A. Treatment. We may use and disclose your Protected Health Information to provide you with treatment services. For example, we may use your Protected Health Information to diagnose or treat your injury or illness and we may disclose your Protected Health Information to physicians, nurses, counselors and other providers and facilities involved in providing health care services to you. We may also disclose your Protected Health Information in order to provide you with various items and services, such as laboratory tests or medications and to make arrangements for home care services, rehabilitation facilities or other health care services you may need. We may contact you to provide appointment reminders, patient registration information or to follow up about your medical care.
B. Payment. We may use and disclose your Protected Health Information so that so that we may bill you or appropriate third party payors for the health care services we provide to you and receive payment for those services. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for your treatment. We may also disclose your Protected Health Information to other health care providers so that those providers may receive payment for services provided to you. For example, we may disclose your Protected Health Information to an ambulance company, so that the ambulance company can receive payment for services provided to you.
C. Health Care Operations. We may use and disclose your Protected Health Information for our health care operations. These are activities that are necessary to run our business. Examples of health care operations activities include quality assessment and improvement activities, protocol development, case management and care coordination, business planning and development, conducting training programs, accreditation, certification and licensing activities, conducting or arranging for medical review, legal services and auditing functions, peer reviews and audits of the process of billing you or a third party for health care services we provide to you. For example, we may use Protected Health Information to review the quality and competence of our health care providers. We may contact you regarding treatment alternatives and related functions. We may also use or disclose your Protected Health Information for certain limited health care operation purposes of other health care providers, health plans or health care clearing houses provided they have or had a treatment relationship with you and the Protected Health Information disclosed pertains to that relationship.
D. Fundraising. We may use and disclose to a business associate or an institutionally related foundation certain limited Protected Health Information to contact you as part of a fundraising effort on behalf of Anderson Hospital, unless you have told us that you do not want to receive communications from us for fundraising purposes. You have the right to opt out of receiving such communications and if you receive a communication from us for fundraising purposes, you will be told how you may request not to be contacted for fundraising purposes in the future.
E. Hospital Directory. For hospital patients, unless you object, if we maintain a facility directory we may use your name, location in the facility, general condition (e.g., fair,stable) 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. This helps your family, friends and clergy to visit you and learn about your general condition.
F. Disclosure to Relatives, Close Friends and Your Other Caregivers. We may use and disclose your Protected Health Information with a family member, other relative, a close personal friend, or any other person identified by you, if we (1) obtain your agreement; (2) provide you with an opportunity to object and you do not express an objection; or (3) reasonably infer, based on professional judgment, that you do not object to the disclosure. If you are not present at the time we share your Protected Health Information or the opportunity to agree or object to the use or disclosure cannot reasonably be provided because of your incapacity or emergent circumstances, we may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of you and if so, disclose the Protected Health Information that is directly relevant to the person’s involvement with your health care.
G. Disaster Relief Purposes. We may use and disclose your Protected Health Information to disaster relief organizations, such as the Red Cross, so that your family can be notified about your condition and location.
H. Limited Data Sets. We may use and disclose a limited data set (i.e., Protected Health Information in which certain identifying information has been removed) for purposes of research, public health, or health care operations. Any recipient of that limited data set must agree to appropriately safeguard your information.
I. Public Health Activities. We may use and disclose your Protected Health Information for public health activities to public health or other appropriate governmental authorities authorized by law to collect and receive such information in order to help prevent or control disease, injury or disability. For example, we may disclose your Protected Health Information for the following:
- To public health authorities to prevent or control disease, injury
or disability, conduct public health surveillance, interventions or
investigations, report certain diseases or report vital events, such
as births and deaths;
- To report child abuse or neglect to the Illinois Department of
Children and Family Services, the Illinois Department of Human
Services or other entities that are legally permitted to receive
- To report information about products and services to the U.S.
Food and Drug Administration for the purposes of activities
related to the quality, safety or effectiveness of the FDA
regulated products or activities;
- To notify a person who may have been exposed to a
communicable disease or who may otherwise be at risk of
contracting or spreading a disease if authorized by law in connection with conducting a public health intervention or
- To report information to your employer regarding work-related
illnesses and injuries or workplace medical surveillance,
consistent with applicable legal requirements; and
- To provide proof of immunization to school consistent with
J. Serious Threat to Health and Safety. We may use and disclose your Protected Health Information as necessary and consistent with applicable law to prevent or lessen a serious and imminent threat to health or safety of a person or the public.
L. Victims of Abuse, Neglect or Domestic Violence. We may use and disclose your Protected Health Information to a governmental authority, including a social service
or protective services agency, authorized by law to receive reports of abuse, neglect or domestic violence, if we reasonably believe that you are a victim of abuse, neglect or domestic violence to the extent required or permitted by law.
M. Judicial and Administrative Proceedings. We may use and disclose your Protected Health Information in the course of a judicial or administrative proceeding, in response to an order of a court or administrative tribunal, or in response to a subpoena, discovery request or other lawful process, subject to certain procedural requirements required by law.
N. Correctional Institutions. If you are in the custody of law enforcement or a correctional institution, we may disclose your Protected Health Information to the law
enforcement official or the correctional institution as necessary for your health, the health of others or certain approved operations of the correctional institution.
O. Law Enforcement Purposes. We may disclose your Protected Health Information to law enforcement officials to report criminal conduct that occurred on premises of our facilities, to locate or identify a suspect, fugitive, material witness or a missing person, to alert law enforcement if a death has resulted from a criminal conduct or to report crime in emergencies if we provide medical care in response to a medical emergency outside of our facilities to alert law enforcement to the commission, nature, location, victims and perpetuators of such crime. In addition, we may disclose Protected Health Information to law enforcement officials regarding a victim of a crime, in response to a subpoena, court order or warrant, administrative request or similar process authorized under law or as otherwise may be required by law.
P. Coroners, Medical Examiners and Funeral Directors. We may disclose your Protected Health Information to a coroner or medical examiner or funeral director so that they can carry out their duties authorized by law and for purposes of identification of a deceased person or determining a cause of death.
Q. Organ and Tissue Procurement. We may disclose your Protected Health Information to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.
R. Research. We may use or disclose your Protected Health Information to further research consistent with applicable legal requirements.
S. Specialized Government Functions. If you are a member of the Armed Forces, we may disclose your Protected Health Information as required by military command
authorities to assure the proper execution of a military mission and with respect to foreign military personnel, to the appropriate foreign military authorities for the same
purpose. We also may disclose your Protected Health Information for conducting national security and intelligence activities, including providing protective services to the President or other persons provided protective services under Federal law.
T. Workers’ Compensation. We may use or disclose your Protected Health Information as authorized by and to the extent necessary to comply with laws relating to Workers’ Compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
U. As required by Law. We may use and disclose your Protected Health Information when required or permitted to do so by law, but only to the extent and under the circumstances provided in such law.
V. Business Associates. We may disclose your Protected Health Information to our business associates which are various vendors who provide services for us requiring access to your Protected Health Information. Examples include software and information technology vendors, vendors providing billing services or vendors that perform transcription services for us. To protect your health information, business associates are required to appropriately safeguard your Protected Health Information.
II. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION REQUIRING YOUR WRITTEN AUTHORIZATION
Obtaining your authorization will be required for most uses and disclosures of psychotherapy notes, uses and disclosures of your Protected Health Information for marketing purposes (with the exception of our face to face communications with you and providing you with promotional gifts of nominal value) and disclosures which constitute
a sale of your Protected Health Information. In addition, for any other activities and purposes other than the ones described above in this Notice, we may only use or disclose your Protected Health Information when you grant us your written authorization. For example, you will need to give us your permission before we disclose your Protected Health Information to your life insurance company. Certain Federal and state laws may require special privacy protections for certain medical information, including information that pertains to HIV/AIDS testing, diagnosis or treatment, mental health services, alcohol or drug abuse treatment services, genetic information and testing, sexual assault or other
types of medical information. This is not an exhaustive list and there may be other information that requires special privacy protections. Sometimes state or Federal laws prohibit disclosure of medical information that is otherwise permitted to be made without an authorization under the HIPAA privacy rules. To the extent any such laws require special protection to any of your medical information and do not permit disclosure of such information without obtaining your written authorization, we will comply with those laws.
III. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
By law, you have the following rights with respect to your Protected Health Information:
Your Right to Revoke your Written Authorization. You may revoke your written authorization to release your Protected Health Information at any time if you provide
written notice to our Privacy Officer, but only as relates to future uses and disclosures, and only where we have not already acted in reliance on your authorization.
Your Right to Request Restrictions on Certain Uses and Disclosures. You have the right to request a restriction on uses and disclosures of your Protected Health information for purposes of treatment, payment or health care operations or to individuals involved in your care. To request such restriction you must make your request in writing to our Privacy Officer. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to
apply (for example, disclosures to a certain family member). We are not required to agree to a requested restriction unless your request is to restrict disclosures for purposes of carrying out payment or health care operations to your health plan, which disclosures are not otherwise required by law, and the Protected Health Information pertains solely to
the item or service for which you, or a party other than the health plan, have paid in full. We will notify you if we don’t agree to your request for restriction. If we agree to your
request for a restriction, we will comply with the restriction unless the information is needed to provide emergency treatment to you. Even if we agree to your request for a
restriction, we will still be permitted to disclose your Protected Health Information to the Secretary of the Department of Health and Human Services, in a hospital directory and
for other purposes described in this Notice when disclosure is permitted without your authorization (e.g., judicial proceedings, public health activities). We may terminate a
previously agreed to restriction, except the restriction which we are required to accept as described above, in which case you will be notified of such termination.
Your Right to Receive Confidential Communications. You may request that you receive communications from us regarding your Protected Health Information by
alternative means (e.g., by mail) or at an alternative location (e.g., alternate address or telephone number). You must make your request in writing and must submit this request
to our Privacy Officer. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted and to what address we may send
bills for payment for services provided to you. We will accommodate all reasonable requests for confidential communications.
Your Right to Receive Notice of Breaches. You have the right under federal and state law to receive notice in the event the security or privacy of your unsecured Protected
Health Information is breached. You do not need to request this notice. We will automatically provide you with this notice when required under federal and/or state law.
Your Right to Inspect and Copy Your Protected Health Information. You have the right to review and obtain a copy of your Protected Health Information. To inspect and
copy your Protected Health Information, you must submit your request in writing to our Health Information Management Department at Anderson Hospital, 6800 State Route
162, Maryville, IL 62062. Phone number: 618-391-6102. If you request a copy of Protected Health Information, we may charge a reasonable cost based fee for the costs of copying, supplies and postage associated with your request, as permitted by law. You may request a copy of your Protected Health Information in electronic format, if we maintain your Protected Health Information in electronic format, and we will comply with your request if your Protected Health Information is readily producible in such format.
Your Right to Amend. You have the right to request an amendment of your Protected Health Information if you believe that the information we have about you is incorrect or
incomplete. You have the right to request an amendment for as long as the information is kept by our organization. Your request for amendment must be in writing, submitted to
our Privacy Officer and provide a reason that supports your request. In certain circumstances, we may deny your request for an amendment (e.g., if you ask us to amend information that is not part of the medical information about you kept by us, if we determine that your medical information is accurate and complete). If we accept your request, we will inform you about our acceptance and make the appropriate corrections. If we deny your request, we will inform you of this decision and give you a chance to submit to us a written statement disagreeing with the denial. We will add your written statement to your records and include it whenever we disclose the part of your Protected Health Information to which your written statement relates.
Your Right to an Accounting. You have the right to request an accounting of certain disclosures we have made of your Protected Health Information. To request this accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period for which the accounting of disclosures is sought, which cannot be longer than six years prior to the date on which your request for accounting is made. The first accounting request within a 12-month period will be free. For additional requests, we may charge you for the reasonable costs of providing the accounting. We will notify you of the cost involved in advance and you may choose to withdraw or modify your request at that time before any costs are incurred.
Your Right to Obtain a Copy of this Notice of Privacy Practice. You have the right to obtain a copy of this Notice upon request. You may ask us to give you a copy of this
Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You also may obtain a copy of this Notice on
our website: www.andersonhospital.org.
If you would like more information on how to exercise these rights, please contact our Privacy Officer at 618-391-6101.
IV. OUR RESPONSIBILITIES
We are required by law to:
- Provide you with this Notice concerning our legal duties and privacy practices
with respect to your Protected Health Information;
- Provide you with notice following a breach of unsecured Protected Health
- Abide by the terms of the Notice of Privacy Practices currently in effect.
V. COMPLAINTS OR FURTHER INQUIRIES
If you have any questions or you would like more information about our privacy practices, please contact our Privacy Officer at 618-391-6101. If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. To file a complaint with us, please direct your complaint to:
6800 State Route 162
Maryville, IL 62062
We reserve the right to amend the terms of this Notice at any time and to make the revised Notice effective for all Protected Health Information that we maintain. We will post copy of the current Notice on our website and have copies available at our facilities. The Notice will specify the effective date of the Notice. A copy of the current Notice will also be available to you by requesting that a copy be sent to you in the mail.
Effective Date: September 23, 2013