Notice of Privacy Practices
Effective April 14, 2003
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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 We Are
This Notice describes the privacy practices of Methodist Medical Center
of Illinois, Methodist Health Services Corporation and the members of
its medical staff, nurses, volunteers, and other personnel ("Methodist,"
"we" or "us"). It also applies to all business associates with whom we
may share information. It applies to your medical information, including
your medical record, for all services provided to you in our clinically
integrated care setting at the hospital, Methodist MedPointes and other
Methodist physician offices and clinics.
We understand that your medical information is confidential and we are
committed to maintaining its privacy. Federal law requires that we
provide you with this Notice of our legal duties and privacy practices
with respect to your medical information. We are required to abide by
the terms of this Notice when we use or disclose your medical
How We May Use and Disclose Medical Information About You
We may use and disclose medical information about you without your prior authorization for the following reasons:
Treatment Purposes. For example, to diagnose and
treat your injury or illness. In addition, 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. We may also disclose your medical information to other providers
involved in your treatment.
Payment Purposes. Such as sending billing
information to Medicare, Medicaid, your health insurer, HMO, or other
company or program that will pay for your health care.
Health Care Operations. For example, we may use
your medical information to evaluate the quality and competence of our
physicians, nurses and other health care workers. We may disclose
medical information to our Patient Advocate in order to resolve any
complaints you may have and ensure that you have a comfortable visit
We may also disclose medical information to other health care providers
when such medical information is required for them to treat you, receive
payment for services they render to you, or conduct certain health care
operations, such as quality assessment and improvement activities and
reviewing the quality and competence of health care professionals.
Patient Directory. If admitted as a patient,
unless you tell us that you object, we will list your name, location,
general condition and religious affiliation in the hospital directory.
(Religious affiliation will only be disclosed to members of the clergy.)
Information in the directory may be released to anyone who asks for you
by name or to members of the clergy.
Disclosure to Family, Close Friends and Other Caregivers.
We may disclose medical information about you to a family member, other
relative, or a close personal friend who is involved in your medical
care or to disaster relief authorities so that your family can be
notified of your location and condition.
If you are not present, or you are incapacitated or in an emergency
situation, we may exercise our professional judgment to decide whether a
disclosure is in your best interest. Under these circumstances, we
would only disclose information that we believe is directly relevant to
the person's involvement with your health care.
Fundraising Communications. We may contact you to
request a tax-deductible contribution to support important activities of
Methodist Medical Center Foundation. If you wish to make a
tax-deductible contribution now or do not want to receive any
fundraising requests in the future, you may contact the Methodist
Medical Center Foundation at (309) 672-5741.
Other Disclosures. We may also use or disclose
medical information about you without your prior authorization for
several other reasons. Subject to certain requirements, we may give out
medical information about you for: Public Health Activities for the
purpose of preventing or controlling diseases; abuse and neglect, to a
governmental authority if we reasonably believe you are a victim of
abuse, neglect or domestic violence; health oversight activities or
inspections, to a health oversight agency that oversees the health care
system; judicial, administrative and law enforcement purposes, for
example, in response to a subpoena or a request by a law enforcement
officer; and we may also disclose your medical information for research
studies, funeral arrangements, organ and tissue donations, workers'
compensation purposes, your health and safety, and when it is required
Uses and Disclosures Requiring Your Written Authorization
For any purpose other than the ones described above, we will only use or
disclose your medical information when you give us your written
authorization. For instance, we will obtain your written authorization
before sending your medical information to your life insurance company
or to the attorney representing the other party in litigation in which
you are involved.
Marketing. We will obtain your written
authorization prior to using your medical information to send you any
marketing materials. We can provide you with marketing materials in a
face-to-face encounter without obtaining your authorization. We are also
allowed to give you a promotional gift of nominal value, if we so
choose, without obtaining your authorization. In addition, we may
communicate with you about products or services relating to your
treatment, case management or care coordination, or alternative
treatments, therapies, providers or care settings without your
Highly Confidential Information. Federal and
Illinois law requires special privacy protections for highly
confidential information about you. Highly Confidential Information
consists of medical information related to: psychotherapy notes; mental
health and developmental disabilities services; alcohol and drug abuse
services; HIV/AIDS testing, diagnosis or treatment; venereal disease(s);
genetic testing; child abuse and neglect; domestic abuse of an adult
with a disability; or sexual assault. In order for us to disclose your
Highly Confidential Information for a purpose other than those permitted
by law, we must obtain your written authorization.
Your Rights Regarding Your Medical Information
For Further Information; Complaints. If you have
questions or areconcerned that your privacy rights have been violated or
you disagree with a decision that we made about access to your medical
information, you may contact our Privacy Office. You may also file
written complaints with the Director, Office for Civil Rights of the
U.S. Department of Health and Human Services. Our Privacy Office will
provide you with the address. We will not retaliate against you if you
file a complaint.\
Right to Request Additional Restrictions. You may
request, in writing, that we not use or disclose medical information
about you for treatment, payment or health care operations or to persons
involved in your care except when specifically authorized by you, when
required by law, or in an emergency. We will consider all requests for
additional restrictions carefully; however, we are not required to
accept them. If you wish to request additional restrictions, please
obtain a request form from our Patient Registration Department or the
Privacy Office and submit the completed form to the Privacy Office. We
will send you a written response.
Right to Receive Confidential Communications. You
may request, and we will accommodate, any reasonable written request for
you to receive your medical information by alternative means of
communication or at alternative locations, such as sending mail to an
address other than your home.
Right to Revoke Your Authorization. You have the
right to revoke your written authorization obtained in connection with
the release of your medical information, except to the extent that we
have taken action in reliance upon it, by delivering a written
revocation statement to our Privacy Office. A written revocation form is
available upon request from the Patient Registration Department or the
Right to Inspect and Copy Your Health Information. You
have a right to look at or get a copy of your medical record file and
billing records maintained by us. Under limited circumstances, we may
deny you access to a portion of your records. If you desire access to
your records, please obtain a record request form from the Health
Information Services Department or your physician's office and submit
the completed form to the Health Information Services Department or your
physician's office. If you request copies, we may charge a fee for the
cost of copying, mailing, or other related supplies.
Right to Amend Your Records. You have the right to
request that we amend your medical record file or billing records by
obtaining an amendment request form from the Health Information Services
Department and submitting the completed form to the Health Information
Services Department. We will comply with your request unless we believe
that the information is accurate or other special circumstances apply.
You have the right to appeal our decision not to amend your medical
Right to Receive an Accounting. You may obtainan
accounting of certain disclosures of your medical information made by us
in the six (6) years prior to your request; however, it does not apply
to disclosures that occurred prior to April 14, 2003. If you request an
accounting more than once during a twelve (12) month period, we will
charge you $0.50 per page of the accounting statement.
Right to Receive Paper Copy of this Notice. Upon request, you mayobtain a paper copy of this Notice, even if you have agreed to receive such Notice electronically.
Right to Change Terms of this Notice. We may
change this Notice atany time. If we change this Notice, we may make the
new Notice terms effective for all medical information that we
maintain, including any information created or received prior to issuing
the new Notice. If we change this Notice, we will post the new Notice
in waiting areas around Methodist Medical Center of Illinois and on our
Internet site at www.methodistmedicalcenter.org. You also may obtain any
new Notice by contacting the Privacy Office.
The effective date of this Notice is April 14, 2003.
You may contact the Privacy Office at:
Methodist Medical Center of Illinois
221 NE Glen Oak
Peoria, IL 61636-0002
Phone: (309) 671-8232