comprehensive family practice medical care in Grayslake... serving Lake County, northern Illinois and southern Wisconsin

In order to help patients get treatment even faster, our forms are available for download.

PROVIDA FAMILY MEDICINE 18931 W. Washington St. Suite 100 Third Lake, IL 60030 847-548-2200 Notice of Privacy Practices January 1, 2007 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. HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU: We may use and disclose PHI for treatment, payment, or health care operations without your consent or authorization. OTHER USES AND DISCLOSURES WE CAN MAKE WITHOUT YOUR WRITTEN AUTHORIZATION FOR WHICH YOU HAVE THE OPPORTUNITY TO AGREE OR OBJECT Individuals Involved in Your Care or Payment for Your Care: We may disclose PHI about you to your family member, close friend, or any other person identified by you if that information is directly relevant to the person’s involvement in your care or payment for your care. OTHER USES AND DISCLOSURES WE CAN MAKE WITHOUT YOUR WRITTEN AUTHORIZATION OR OPPORTUNITY TO AGREE OR OBJECT Required By Federal, State or Local Law Public Health Activities Abuse, Neglect, or Domestic Violence Health Oversight Activities Lawsuits and Other Legal Proceedings Law Enforcement Coroners, Medical Examiners, Funeral Directors Organ and Tissue Donation Research To Avert a Serious Threat to Health or Safety Specialized Government Functions Workers’ Compensation Disclosures Required by HIPAA Privacy Rule Incidental Disclosures Limited Data Set Disclosures OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRE YOUR AUTHORIZATION All other uses and disclosures of PHI about you will only be made with your written authorization. If you have authorized us to use or disclose PHI about you, you may later revoke your authorization at any time, except to the extent we have taken action based on the authorization. II. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU: Under federal law, you have the following rights regarding PHI about you: Right to Request Restrictions Right to Receive Confidential Communications Right to Inspect and Copy Right to Amend Right to Receive an Accounting of Disclosures Right to a Paper Copy of this Notice III. COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the United States Department of Health and Human Services. To file a complaint with our office, please contact our Privacy Official at the address and number listed below. We will not retaliate or take action against you for filing a complaint. IV. QUESTIONS: If you have any questions about this Notice, please contact our Privacy Official at the address and telephone number listed below. V. PRIVACY OFFICIAL CONTACT INFORMATION: You may contact our Privacy Official at the following address and phone number: Consuelo I. Salazar, 1170 East Belvidere Road, Suite 102, Grayslake, Illinois 60030-2073, 847-548-2200. I acknowledge that I was provided with the Notice of Privacy Practices of PROVIDA FAMILY MEDICINE. HOME | SERVICES | DR. SALAZAR | ROSALVA ACOSTA PAC | PHILOSOPHY | OFFICE | CONTACT © 2007     Provida Family Medicine     847-548-2200