Summary of Notice
We, at Centegra Health System, believe that your health care experience here with us is personal and private. Accordingly, Centegra places privacy and confidentiality at the forefront of all that we do. It is our pledge to you that we will protect the privacy and confidentiality of your medical information maintained and created by Centegra during your health care experience.
Enclosed you will find information on how the medical staff, associates and volunteers at Centegra and all its locations and various entities work to safeguard your privacy consistent with Centegra values as well as federal privacy regulations, including the Health Insurance Portability and Accountability Act, known as HIPAA. Centegra takes HIPAA very seriously. We work closely with all entities of the Centegra Health System to ensure that your medical information is kept confidential and only used or disclosed in accordance with this Notice, HIPAA and all other applicable laws. This Notice also discusses your rights as a patient under the law.
We encourage you to read this entire Notice, understand its contents and seek further information from your specific health care providers if needed. This Notice is available on our website, Centegra.org, and at any one of our patient registration sites. For your convenience, a brief summary of the Notice follows:
Centegra Health System may use or disclose some of your medical information to:
- Medical Staff and personnel who provide you with care;
- Family and friends involved in your care;
- Process payment for the medical care received;
- Ensure that we follow all rules, regulations and laws pertaining to our provision of healthcare;
- Review and improve associate performance, the quality or cost of care and efficiency of resources;
- Comply with legal requirements for judicial or administrative proceedings or for the reporting of certain crimes, violence or abuse;
- Tell you about our services and their benefits to your care;
- Research personnel to develop and improve treatments;
- The Centegra Foundation for fundraising efforts in support of Centegra Health System; and
- Clergy and your visitors through our facility directory.
Your rights as a Centegra patient are to:
- See and obtain a copy of your medical information;
- Ask us to limit or restrict who sees or learns about your medical information;
- Ask us to amend your medical information if you feel it is incorrect;
- Ask us to communicate with you by using a specified phone number or address;
- Ask us to see the list of people who have received your medical information for reasons other than for treatment, payment or healthcare operations; and
- Communicate complaints.
If you have any further questions, comments, concerns or complaints regarding the handling of your medical information please let us know by contacting our Director of Compliance at (815) 759-4567 and we will be happy to respond.
Notice of Privacy Practices
Effective Date: September 23, 2013
1. Our Pledge Regarding Health Information
Centegra Health System understands that information about you and your health is personal. We are committed to protecting the privacy of your health information and pledge to maintain the confidentiality of your health information as stated in this Notice and required by applicable law.
2. Understanding Your Health Information
Each time you visit a Centegra Health System facility, physician, or other healthcare provider, a record of your visit is made. Your health record includes, but is not limited to, your symptoms, test results, diagnoses, treatments, insurance, demographic information and care plan. This information, referred to as your health or medical record, may be kept on paper, electronically, or stored by other media such as photographs, videotapes, or other images and serves as a:
- Basis for planning your care and treatment;
- Means of communication among the many health professionals who contribute to your care;
- Legal document describing the care you received;
- Means by which you or a payer, such as Medicare, Medicaid or a commercial insurance company, can verify that services billed were actually provided;
- Tool in educating health professionals;
- Source of information for public health officials charged with improving the health of the nation;
- Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve;
- Source of information for facility planning and marketing; and
- Source of information for medical research.
Understanding what is in your health record allows you to ensure its accuracy. Understanding how your health information is used helps you to better understand who, what, when, where, and why others may access it and make informed decisions when authorizing disclosures to others.
3. The Purpose of This Notice
By law, Centegra Health System, and its entities, including but not limited to, Centegra Hospital-McHenry, Centegra Hospital-Woodstock, Centegra Specialty Hospital Woodstock, Centegra Physician Care, Centegra Management Services and Centegra Clinical Laboratories must comply with specific requirements regarding how Centegra Health System may use, disclose and store your protected health information. In order to comply with these laws, Centegra Health System must provide you with this Notice of Privacy Practices.
This Notice applies to all of the records of your care generated by Centegra Health System facilities and providers for the purpose of providing treatment, obtaining payment or for other hospital operations, whether made by facility personnel or your personal doctor. Your personal doctor, if not a member of Centegra Physician Care, may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
This Notice will tell you the ways in which we may legally use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. The terms ‘medical’ and ‘health’ information and records have the same meaning.
4. Who Will Follow This Notice
This Notice applies to privacy practices of the following Centegra Health System entities and their health care practice locations:
- Centegra Hospital-McHenry;
- Centegra Hospital-Woodstock;
- Centegra Management Services;
- Centegra Physician Care; and
- Centegra Clinical Laboratories, LLC.
This Notice also covers the following personnel at each of the above Centegra Health System entities unless the healthcare provider gives you their own separate notice of privacy practice:
- All healthcare professionals, including students, allowed to enter and access information in your medical record;
- All employees, physicians on the medical staff and other Centegra Health System personnel in all departments and units;
- Any hospital volunteer we allow to help you while you are patient at Centegra Health System;
- Health care professionals at other facilities who may have access to your health information at their locations and share it with us to assist in reviewing past treatment information as it may affect current treatment.
Application of this Notice to any independent contractors who are not employees or agents of Centegra Health System, but are governed under this Joint Notice of Privacy Practices, is solely for your convenience and is not meant to imply, infer, or create any agency or employment relationship between the physicians and the facility, either actual or implied. In addition, this Notice does not alter, limit, or modify any consents for treatment or procedures in effect during the time care is provided at any applicable Centegra Health System facility. The physicians exercise their own medical judgment in providing treatment and professional services. They are solely responsible for their own compliance with federal and state privacy laws.
5. Centegra’s Duties
By law Centegra Health System and the entities identified above are required to:
- Make sure that any medical information that identifies you is kept private;
- Give you this Notice of Privacy Practices describing our legal duties and privacy practices with respect to your medical information;
- Follow the terms of the most current Centegra Health System Notice of Privacy Practices; and
- Notify you if we discover a breach of your health information, unless after a risk assessment has been performed, it is demonstrated that there is a low probability that your health information has been compromised.
6. Uses and Disclosures
The following categories describe and provide some examples of different ways that we will use and disclose health information.
- Treatment. We will provide health information about you to physicians, nurses, technicians, students, and other healthcare team members who need the information to provide you treatment or services. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The physician may need to tell the dietitian if you have diabetes so that we arrange for appropriate meals. Different departments of the hospital also may share your health information to coordinate things you need such as prescriptions, lab work, and x-rays. We will also disclose health information about you to your physicians or other persons that will assist in continuing your treatment outside our facility. For example, we may share your health information with other hospitals, physicians, nursing homes, or other health care providers as necessary to continue your care. We may contact you to provide appointment reminders or treatment alternatives.
- Payment. Unless you specifically restrict uses or disclosures related to payment and we agree to your restriction, we will use your health information to bill for and obtain payment for treatment services you receive at our facility. For example, a bill/claim may be sent to you, an insurance company, third party payor, authorized agent, claims review organization, or collection agency for payment pursuant to your health plan. We may need to give information about surgery, medical treatment and continuum of care needs you received or will receive so that the health plan will pay us or reimburse you for the services. For pre-certification purposes, we may also tell your health plan about a treatment you are going to receive to obtain prior approval or determine whether your plan will cover the treatment. We may disclose your health information to other health care providers, such as an ambulance service, for the payment purposes of those providers.
- Health Care Operations. We may use and disclose health information about you for facility operations. This information is used in an effort to continuously improve the quality and effectiveness of the health care services we provide. For example, members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. We may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to physicians, nurses, and students for educational purposes. We may disclose limited health information about you to other health care providers for certain purposes of their operations.
- As Required or Permitted by Law. Sometimes we must report some of your health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
- Contracted Services. There are some services provided in our organization through contracts with other service providers. Examples include, but are not limited to, physician services in radiology, collection agencies for payment services, electronic data storage vendors for storage of medical records and business documents, or electronic transmission or copy services we use when copying or sending your medical record in a secure manner. These vendors may also be referred to as “Business Associates”. When these services are contracted, we may disclose your health information to these contracted service providers to assist in your care or to also assist us in our business activities, such as a billing company, computer company or accountant. They may bill you, your insurance company or third party payor directly for payment by your health plan for the services rendered. To protect your health information, all contracted service providers and any of their subcontractors who may have access to your health information on behalf of the contracted service providers, have assured us in writing that they will appropriately safeguard your health information in accordance with applicable law.
- Correctional Institutions. Should you be an inmate of a correctional institution, we may disclose to the institution or its agents health information necessary for your health and the health and safety of other individuals.
- Hospital Directory. Unless you notify us that 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 individuals who ask for you by name as well as government agencies and disaster relief organizations in the event of a disaster.
- Family/Close Friend. Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information about you when that person is involved in your care or payment related to your care.
- Food and Drug Administration (FDA). We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
- Fundraising. We may contact you as part of fundraising efforts in support of Centegra Health System, unless you opt out of receiving such communications.
- Health Oversight Activities. We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs.
- Law Enforcement. We may disclose health information to law enforcement for law enforcement purposes and investigations.
- Lawsuits and Disputes. We may disclose your health information during a judicial or administrative legal proceeding in response to an order of court or other tribunal to the extent that this disclosure is authorized and, in certain conditions, in response to a legal subpoena, discovery request or other lawful process. Illinois law may require your written permission to disclose your health information in certain proceedings involving information obtained by certain providers such as physicians or rape and crisis counselors.
- Information Used in Disciplinary Proceedings. Illinois law may require your written permission if certain health information is to be used in various review and disciplinary proceedings of healthcare professionals by state authorities.
- Limited Data Sets. We may use or disclose a limited data set (i.e., in which certain identifying information has been removed) of your 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.
- Appointment Reminders and Certain Other Communications. We may use health information to contact you in order to provide appointment reminders, to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you so long we are not receiving financial consideration in exchange for making the communication. This communication may come in the form of newsletters, mail outs or other means regarding treatment options, disease management programs, wellness programs, or other community based initiatives or activities in which our facility is participating.
- Medical Examiners, Coroners, and Funeral Directors. We may disclose health information to medical examiners, coroners, and funeral directors consistent with applicable law to carry out their duties.
- Minors. We will follow state law as it relates to personal representatives or non-emancipated minors.
- Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, about your location and general condition. We may also disclose your health information to an organization, such as the American Red Cross, assisting in a disaster relief effort, so that your family can be notified about your condition, status and location during a disaster emergency. If we are reasonably able to do so while responding to the disaster emergency, we will try to find out if you would like us to share your information with such an organization.
- Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
- Patient. During the course of your treatment and services at our facility, there may be encounters in which a physician, nurse, or other health team member may need to discuss with you your health condition and plan of treatment in an area where the presence of others is unavoidable. We will make every reasonable effort to maintain the confidentiality of your health information during these situations.
- Public Health. As required by law, we may disclose your health information to certain government agencies and others charged with preventing or controlling disease, injury, or disability. Some examples include reporting communicable diseases, work-related illnesses or other diseases and injuries as permitted by law; reporting of births and deaths, reporting reactions to drugs and problems with medical devices and providing the required immunization records of a student or prospective student to the school.
- Research. We may disclose health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
- Specialized Government Functions. Under certain conditions, we may disclose your health information if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, we may disclose, in certain circumstances, your information to the foreign military authority. We also may disclose your health information to authorized federal officials for conducting national security and intelligence activities, and for the protection of the President, other authorized persons or heads of state.
- To Avoid a Serious Threat to Health or Safety. As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.
- Worker’s Compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
7. Confidentiality of Mental Health/Developmental Disabilities, and Alcohol or Drug Abuse Information
The confidentiality of mental health/developmental disabilities and alcohol or drug abuse patient records maintained by this program is protected by Federal and State laws. Generally, Centegra Health System may not acknowledge to anyone outside the program that a patient attends the program, or disclose any information identifying a patient participating in any of these programs unless one of the following conditions is met:
- The disclosure is for the purpose of payment for services received at our facilities.
- The patient gives written authorization for the disclosure.
- The disclosure is required by a court order.
- The disclosure is made to medical personnel in a medical emergency.
- The disclosure is made during a review by a federal or state agency.
- The disclosure is made for audit or accreditation purposes.
- Violation of the Federal or State laws is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal and State laws.
8. Disclosures Requiring Specific Authorization
In addition to the special protections that apply to mental health, alcohol and drug abuse information, there are special privacy protections that apply to AIDS/HIV-related information, genetic information, and certain circumstances in which state law requires Centegra Health System to obtain a separate written authorization from you prior to our use or disclosure of your health information.
Most uses and disclosures of health information for marketing purposes and uses and disclosures of psychotherapy notes will only be made with your specific written authorization. All uses and disclosures of health information that would constitute a sale will be made only with your written authorization.
In these circumstances your health information may not be released unless either we have your express written authorization or we are required by federal or state law to release the information. After you sign a written authorization, you may revoke your authorization, except to the extent that action has already been taken, by submitting a written request. More specific information may be obtained from Centegra Health System’s Privacy Office.
9. Other Uses and Disclosures
All other uses and disclosures not described in this Notice will be made only with your authorization. If you give us authorization to use and disclose your information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization.
10. Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:
- Right to Inspect and Copy Your Medical Record.
- Right to Request an Amendment to Your Medical Information.
- Right to a List of Certain Disclosures.
- Right to Request Restrictions.
- You have the right to see and receive a copy of your health information*, including medical and billing records, but excluding psychotherapy notes.
- Reasonable fees may apply for the cost of copying, mailing or other expenses associated with complying with your request.
- In limited circumstances we may deny your request to see or obtain copies of your health information. For example, a denial may occur if, in the professional judgment of a patient’s physician, the release of the information would be reasonably likely to endanger the life or physical safety of the patient or another person.
- You have the right to request corrections or additions to your health information* if you feel that the health information we have on record is wrong or that information is missing.
- If the health information that you are seeking to amend is not kept by Centegra Health System but, rather, by another healthcare provider, we cannot act on your behalf to amend that record. You must contact them directly.
- Your request to amend your health information must be in writing and must state the reason for the requested amendment.
- We may deny your request to amend based on one of the following situations:
- The request was not in writing;
- The request did not include a supporting reason;
- The information seeking to amend was not created by Centegra Health System and the creator of the information is available to make the amendment;
- The information seeking to amend is not part of the designated medical record; or
- The information is accurate and complete.
- You have the right to request a report of certain disclosures of your health information made by us*. This is a list of those individuals or entities who have received your health information from Centegra Health System.
- The report does not include disclosures made for treatment, payment, health care operations, some disclosures required by law, or disclosures made via a signed authorization.
- Your request must state the period of time desired for the report, which must be within the 6 years prior to your request and exclude dates prior to April 14, 2003. The first report of disclosures is free but a fee will apply if more than one request is made in a 12-month period.
- You have a right to request restrictions on how we can use and share your health information*. We will consider all requests for restrictions carefully but are not required to agree to all restrictions.
- Unless required by law, you have the right to restrict Centegra Health System from disclosing to your healthcare plan, specific health information pertaining to the medical services you, or person(s) on your behalf, paid out of pocket and in full before receipt of those medical services*.
- Right to Request Confidential Communications.
- You have the right to request that we communicate to you about medical matters in a certain way or at a certain location. For example, you may request that we use a specific telephone number or address to communicate with you*.
- Your request must be in writing.
- Centegra Health System will accommodate all reasonable requests.
- Right to Receive a Paper Copy of this Notice.
- You have the right to receive a paper copy of this Notice upon request.
Requests marked with an asterisk (*) must be made in writing. Contact the Centegra Compliance Director for the appropriate form for your request or obtain the appropriate form from the website, www.centegra.com.
We reserve the right to revise this Notice. Each time you register for health care services at a site covered by this Notice, the most current copy of this Notice will be available for you.
If you believe your privacy rights have been violated, we encourage you to communicate your concern by contacting the Centegra Assistance Line at 815-759-4142 and asking for our Compliance Director. We will reasonably and diligently investigate all complaints and the corresponding treatment/services you received from us which may be the subject of the complaint. You will not be negatively affected, intimidated or retaliated against by Centegra Health System if you choose to file a complaint on your behalf.
If you wish to file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services, you may submit a written complaint to the regional address:
U.S. Department of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601.
If you have any additional questions, comments or complaints about your privacy or this Notice, please contact:
Centegra Health System
Director of Compliance, Security Officer & Privacy Officer
4209 W. Shamrock, St. B
McHenry, IL 60050
Phone: (815) 759-4567