ILLINOIS REGIONAL PAIN INSTITUTE, S.C.

THE REGIONAL PAIN INSTITUTE, LLC

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.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.

We understand that medical information about you is personal and therefore we are committed to protecting that health information. As required by HIPAA we have prepared this explanation of our Privacy Practices on maintaining your personal health information, how we may use and disclose your information, and follow the terms of the notice that is currently in effect as follows:

We may use and disclose medical information about you:

  • For Treatment (providing, coordinating, or managing health care and related services to another healthcare facility or to a specialist as part of the referral.)
  • To obtain Payment (such as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. Example: sending billing information to your insurance company and/or Medicare.)
  • To Support our Healthcare Operations: (includes the business aspects of running our practice, such as conducting quality assessment to improve treatment methods, auditing function, cost-management analysis and customer service.)

We may use or disclose medical information about you, subject to certain requirements, without your prior authorization for several other reasons: public health purposes, abuse or neglect reporting, health oversight audits or inspection, research studies, workers’ compensation purposes and emergencies. We also disclose medical information when required by law, such as response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders. We may also create and distribute de-identified health information by removing all reference to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other situations not covered by this notice will be made only with your written authorization. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.

Your rights regarding medical information about you:
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer listed at the end of this notice.

  • The right to inspect or get a copy of your medical information that we use to make decisions about your care. If you request copies, there will be a fee for the cost of copying, mailing or other related supplies.
  • The right to amend your protected health information. We may deny your request to amend a record if we determine that the record is accurate.
  • The right to receive a list of those instances where we have disclosed medical information about you, other than for treatment, payment or healthcare operations. The request must state the time period desired for the accounting and starting after April 14, 2003. We may charge a fee according to our cost of producing this list. We will inform you of the cost before you incur any costs.
  • The right to request that medical information about you will be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to communicate with you.
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other persons identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

If you are concerned that your privacy rights may have been violated or you disagree with a decision we made about access to your records, you may contact our Privacy Officer listed at the end of this notice. Finally you may send a written complaint to the U.S. Department of Health & Human Service office of Civil Rights. Our Privacy Officer can provide you the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.

For more information or to file a complaint:

Illinois Regional Pain Institute
Attn: Privacy Officer
5401 N. Knoxville Avenue, Suite 107
Peoria, IL 61614
Phone: (309) 692-PAIN (7246)
Fax: (309) 692-7226
The Regional Pain Institute, LLC
Attn: Privacy Officer
21321 E. Ocotillo Rd. Suite M131
Phoenix, AZ 85142
Phone: (480) 636-1225
Fax: (480)636-8890