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Palos Respects Your Right to Privacy

As a patient at Palos Community Hospital your right to privacy is highly respected. All information and records related to your care are kept confidential and available only to authorized users. Palos does not not publish photographs or patient information without written consent. 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.

Palos Community Hospital is committed to providing you with high quality health care and to forming a relationship with you that is built on trust.  That means respecting your privacy and confidentiality of your protected health information.  Protected health information includes any personal or demographic information that may identify you and that relates to your past, present or future physical or mental health condition and healthcare services.  We protect your privacy and confidentiality rights by creating and practicing policies and procedures that allow access to your protected health information only for legitimate reasons.  We may use or disclose identifiable health information about you without your authorization for several reasons.  Subject to certain requirements, we may disclose health information without your authorization for:  

Treatment:  We may use your protected health information to provide you with medical treatment and services.  We may disclose your protected health information to doctors, nurses, technicians or other personnel involved in your care.  For example, your information may be provided to a physician to whom you have been referred, family practitioner, physical therapists, home health providers, laboratories, nurse case managers, or others to ensure that the healthcare providers have the necessary information to diagnose or treat you appropriately. 

Payment:  We may use your protected health information, as necessary, to obtain payment for treatment and services from you, an insurance company or a third party.  For example, we may need to provide information about surgery you received at the hospital to your health plan so that they will pay us, or reimburse you, for the treatment.  Or, we may tell your health plan about a planned treatment to determine if it is covered or to obtain prior approval. 

Healthcare Operations:  We may use and disclose your protected health information for hospital operations.  These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care.  For example, we may use protected health information to review our treatment and services and evaluate the performance of our staff in caring for you.  We may also combine information about many patients to evaluate what services are needed or whether new treatments are effective.  We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.  

Others Involved In Your Care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person's involvement in your healthcare.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  In addition, we may disclose your medical information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.  

Required By Law:  We will disclose your protected health information when required to do so by federal, state or local law.  

Other Disclosures:  We may disclose health information without your authorization in certain situations pertaining to public health purposes, law enforcement, judicial or administrative requests, government regulation, coroners or medical examiners, emergencies, accreditation or auditing.

Other Uses of Medical Information:  In any other situation, we will request your written authorization before using or disclosing any identifiable health information about you.  We may not use or disclose psychotherapy notes contained in your protected health information.  We may not sell your protected health information or use or disclose your protected health information for marketing purposes without your authorization.  If you choose to sign an authorization to disclose information, you can later revoke your authorization in writing to stop any future uses and disclosures.  We may change our policies at any time.  Before we make a significant change in our policies, we will change our notice and post a new notice throughout our facilities.  You may also request a copy of our notice at any time.  For more information about our privacy practices, you may contact the person listed below. 

Right to Request Restrictions on Uses and Disclosures:  You have the right to request that we limit the use and disclosure of medical information about you for treatment, payment and healthcare operations.  We are not required to agree to your request.  If we agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation. You also have the right to request that we restrict disclosures of your medical information and healthcare treatment to a health plan (health insurer), when that information relates solely to a healthcare item or service which you, or another person on your behalf (other than a health plan), has paid us for in full. Once you have requested such restriction in writing, and your payment in full has been received, we must follow your restriction.  Please note that you are responsible for notifying any downstream providers (for example, a specialist) and making additional restriction requests to those providers. 

Right to Inspect and Obtain a Copy of Your Health Information:  If you wish to obtain a copy of your health information, your written authorization is required prior to receiving the records.  There will be a charge for obtaining a copy of your records as allowed for by the State of Illinois.  

Right to an Accounting of Disclosure:  You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes.  

Right to Amend:  If you believe that information in your record is incorrect or if important information is missing, you have the right to request in writing that we correct the existing information or add the missing information.  

Right to Request Confidential Communications:  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  You must make your record in writing to Medical Records.  We will accommodate all reasonable requests.  

Right to a Paper Copy of This Notice:  You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.  

Covered Entity:  Palos Community Hospital has established detailed policies and procedures regarding employee access to medical information and knows that it is available to them only to continue to provide care to you or for other limited, but legitimate, reasons. A violation of confidentiality or the failure of an employee to protect your information from accidental or authorized access will not be tolerated.  

Complaint Resolution:  If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.  You will not be retaliated against for filing a complaint.  

Contact Information:  We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices described in this notice, and notify affected individuals following a breach of unsecured protected health information.  

Uses and Disclosures of Medical Information

Palos Community Hospital is committed to providing you with high quality health care and to forming a relationship with you that is built on trust. That means respecting your privacy and confidentiality of your medical information. We protect your privacy and confidentiality rights by creating and practicing policies and procedures that allow access to your personal medical information only for legitimate reasons. We may use or disclose identifiable health information about you without your authorization for several reasons. Subject to certain requirements, we may disclose health information without your authorization for:

Uses Disclosure
Treatment and Payment    Public Health Purposes
Health-related Benefits and Services Law Enforcement for Specific Circumstances
Health Care Operations      Judicial or Administrative Requests
Appointment Reminders Government Regulation
Treatment Alternatives  Coroner or Medical Examiner
Individuals Involved in Your Care Emergencies
Research Accreditation
Serious Threat To Health and Safety   Auditing Purpose

In any other situation, we will request your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke your authorization in writing to stop any future uses and disclosures. We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post a new notice throughout our facilities. You may also request a copy of our notice at any time. For more information about our privacy practices, you may contact the person listed below.

Individual Rights

  • You have the right to inspect and obtain a copy of your health information. If you wish to obtain a copy of your health information, we will charge you 89 cents per page for pages 1 to 25, 59 cents per page for pages 26 to 50 and 30 cents per page for all pages in excess of 50. Copies from microfilm/fiche are $1.49 per page.
  • You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes.
  • If you believe that information in your record is incorrect or if important information is missing, you have the right to request in writing that we correct the existing information or add the missing information.

Covered Entity

Palos Community Hospital has established detailed policies and procedures regarding employee access to medical information and knows that it is available to them only to continue to provide care to you or for other limited, but legitimate, reasons. A violation of confidentiality or the failure of an employee to protect your information from accidental or authorized access will not be tolerated.

Complaint Resolution

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

Contact Information

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices described in this notice.

If you have any questions or complaints, please contact:

Director of Medical Records
Palos Community Hospital
12251 South 80th Avenue
Palos Heights, Illinois 60463
Phone: (708) 923-4663