Community First Medical Center

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.

I. COMMUNITY FIRST MEDICAL CENTER COMMITMENT TO PRIVACY

At Community First Medical Center, we care about your privacy and are committed to protecting and preserving it. We understand that protected health information (PHI) about you is personal and that you may be concerned over how it is used. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical health or condition, treatment or payment for health care services.

This Notice of Privacy Practices describes the limited ways in which Community First Medical Center may use and disclose protected health information about you. This Notice also describes your rights to access and control your protected health information. Community First Medical Center will comply with the privacy practices described in this Notice and to do our best to treat protected health information about you with the utmost care.

This Notice applies to all use and disclosure of protected health information that is made by health care professionals, staff, employees, students, trainees, volunteers and business associates of Community First Medical Center. It also applies to any sharing of protected health information among Community First Medical Center facilities and locations.

Your personal doctor may have different policies regarding use and disclosure of protected health information about you. You should be sure to check with each of your personal doctors and obtain a copy of the notice of privacy practices applicable to their respective use and disclosure of protected health information.

II. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

Your protected health information may be used and disclosed by our physicians, our staff and others outside of our facility that are involved in your care and treatment for the purpose of providing health care services to you, to support business operations of Community First Medical Center, to obtain payment for your care, and any other use authorized or required by law.

For Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may share information about you with doctors, nurses, technicians, students or other Community First Medical Center personnel who are involved in taking care of you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure the necessary information is accessible to diagnose or treat you.

For Payment. Your protected health information will be used, if requested by you, to bill or obtain payment for your health care services. For example, we may need to give information to your insurance company about a surgery you had in order for the insurance company to pay for your surgery. We also may tell your insurance company about treatment you are going to have in order to make sure your insurance company will pay for the treatment.

For Health Care Operations. We may use or disclose, as needed, your protected health information in order to support the business activities of Community First Medical Center. These activities include, but are not limited to, quality assessment, employee review, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room for your appointment. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law; public health; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; coroners, funeral directors and organ donation; research; criminal activity; military activity and national security; workers’ compensation; inmates; and other required uses and disclosures. Under the law, we must make disclosure to you upon your request, and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). State laws may further restrict these disclosures in some states.

Hospital Directory. Our hospital may include certain limited information about you in a directory while you are a patient/resident with us. We compile this information so that your family, friends and clergy can visit you while you are with us and know how you are doing. This information may include your name, location, general condition (for example, fair, stable, critical, etc.) your religious affiliation. This directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest, pastor, cleric or rabbi, even if they do not ask for you by name. You may restrict or prohibit the use or disclosure of this information by notifying our registration staff.

III. USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless permitted or required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. Your protected health information will not be used for fundraising. You may revoke this authorization, at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization

IV. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You may request access to or an amendment of your protected health information, confidential communications, a restriction on the use or disclosure, or an accounting of disclosures of your protected health information by submitting a written request to:

Attn: Privacy Officer
Community First Medical Center
5645 West Addison Street
Chicago, Illinois 60634

You have the right to require a restriction of your protected health/personal information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, except if the requested restriction is on a disclosure to a health plan for a payment or health care operations purpose regarding a service that has been paid in full out-of-pocket. In other cases, if your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another service provider.

You have the right to request to receive confidential communications from us by alternative means or at an alternate location. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

You may have the right to amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to our statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures of your protected health information that we have made, paper or electronic, except for certain disclosures which were pursuant to an authorization, for purposes of treatment, payment, healthcare operations (unless the information is maintained in an electronic health record);or for certain other purposes. You have the right to obtain a paper copy of this Notice, upon request, even if you have previously requested its receipt electronically by e-mail.

V. CHANGES TO COMMUNITY FIRST’S PRIVACY PRACTICES AND THIS NOTICE

We reserve the right to revise this Notice and to make the revised Notice effective for protected health information we already have about you as well as any information we receive in the future. You are entitled to a copy of the Notice currently in effect. Any significant changes to this Notice will be posted on our website at cfmedicalcenter.com. You then have the right to object or withdraw as provided in this Notice.

VI. BREACH OF HEALTH INFORMATION

We will notify you if a reportable breach of your unsecured protected health information is discovered. Notification will be made to you no later than sixty (60) days from the breach discovery and will include a brief description of how the breach occurred, the protected health information involved and contact information for you to ask questions.

VII. QUESTIONS OR COMPLAINTS

Questions or complaints about this Notice or how we handle your protected health information should be directed to our Privacy Officer at the following:

Attn: Privacy Officer
Community First Medical Center
5645 West Addison Street
Chicago, Illinois 60634
Tel: 773-527-5024

If you are not satisfied with the manner in which a complaint is handled you may submit a formal complaint to the Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this Notice of our legal duties and privacy practices with respect to protected health information and to notify affected individuals following a breach of unsecured protected health information. If you have any questions about this Notice, please ask to speak with our Privacy Officer.

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