Commitment to Safeguard your Medical and Personal Information
This Notice provides an overview of the privacy practices of Velona Health PLLC (also referred to in this Notice as “we,” “us,” and/or “our”). The privacy practices described in this Notice will be followed by all Velona Health PLLC healthcare professionals, employees, staff, trainees, students, volunteers, and business associates. If you have any questions about this Notice, please contact our Privacy Manager, Dr. CJ Mimee, PT, DPT, RYT.
This Notice describes how protected health information (defined below) about you may be used and disclosed and how you can get access to this protected health information. This Notice applies to all protected health information held in any form by Velona Health PLLC. Protected health information (also referred to in this Notice as “medical record,” “health information,” and/ or “information”) is your individually identifiable information, whether in electronic, paper, or oral form, which may include, but is not limited to, your geographic information, your demographic information, information on healthcare services you have received in the past, present or which you may receive in the future, full-face photographs and any comparable images of you, and any unique numbers that may identify you.
How We May Use and Disclose Medical Information About You
Uses and Disclosures Without Authorization
For Treatment: We may use medical information about you to provide you with treatment or services. We may disclose medical information or other information about you to physicians, nurses, medical, physical or occupational therapy students, and other health care personnel who provide you with health care services or are involved in your care.
For Payment: We may use and disclose medical information about you in order to bill and collect payment for the treatment and services we provide you. We may also provide medical information about you to our business associates, such as billing companies. We require these business associates to appropriately safeguard the privacy of your information and not to disclose it to anyone else. We may also provide information to other health care providers that have treated you or provided services to you to assist us or them in obtaining payment.
For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to operate Velona Health PLLC, and to make sure that all of our patients receive quality care. For example, we may use your medical information in order to evaluate the quality of health care services you received or to evaluate the performance of the health care professionals who provide health care services to you. We may also disclose medical information about you to another health care provider or health plan with which you have a relationship for such things as quality assurance and case management. We may also provide medical information about you to our business associates, attorneys, consultants, and others to make sure that we’re complying with the laws that affect us. We require that these business associates appropriately safeguard the privacy of your information.
Appointment Reminders and Services: We may use and disclose medical information about you to provide appointment reminders or test results.
Health-Related Products and Services: We may use and disclose medical information about you to tell you about health-related products or services necessary for your treatment, to advise you of new products and services that we offer, to provide general health, fitness and wellness information.
Individuals involved in your care or payment for your care: We may use and disclose medical information about you to a family member, friend, or other person who is involved in your care or the payment for your health care. We may disclose medical information about you to an organization assisting in disaster relief efforts so that your family can be notified about your condition, status and location. You have the right during registration to restrict what information is provided and/or to whom.
As Required By Law: We will disclose information about you when required to do so by Federal, State or local law. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence, when dealing with gunshot wounds, to report reactions to medications or problems with products, or to notify people of recalls of products they may be using.
To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety, or to the health and safety of the public or another person. Any such disclosure, however, would only be to someone able to help prevent the threat or lessen such harm.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may use and disclose medical information about you in response to a court or administrative order. We may also use and disclose medical information about you in response to a court or administrative ordered subpoena or discovery request, but only after efforts have been made to tell you about the request.
Public Health Activities: We may disclose medical information about you for public health activities. For example, we may report information about various diseases as required by law.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Minors: We may release or be required to release medical information about minors to their parents or legal guardians in accordance with Illinois law. However, in instances where Illinois law allows minors to consent to their own treatment, information will not be released to a minor’s parents without the minor’s consent unless otherwise specifically allowed under Illinois law.
Workers’ Compensation: We may release medical information about you for workers’ compensation or similar agencies as necessary to determine if you are eligible for benefits for work-related injuries or illness.
Military and Veterans: If you are a member of the Armed Forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may also disclose medical information about you to the Department of Veteran’s Affairs upon your separation or discharge from military services. This disclosure may be necessary to determine if you are eligible for certain benefits.
Employers: We may release medical information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either 1) to conduct an assessment relating to a medical examination of your workplace, or 2) to determine the extent of your work- related illness or injury. In such circumstances we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you sign a specific authorization for the release of that information to your employer.
National Security and Intelligence: We may use and disclose medical information about you for national security purposes, such as protecting the President of the United States, or foreign heads of state, or for conducting intelligence operations.
Uses and Disclosures Requiring Authorization
Other Uses and Disclosures of Medical Information: Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization; however, we cannot take back any disclosures we have already made based on your prior permission.
HIV/AIDS Information: Use and disclosure of any medical information about you relative to HIV testing, HIV status, or AIDS, is protected by Federal and State law. Generally, an authorization must be obtained for the disclosure of such information; however, State law may allow for disclosure of information for public health purposes.
What Rights You Have Regarding Your Medical Information
The Right To Inspect and Copy: You have the right to inspect and receive a copy of the medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and receive a copy of medical information that may be used to make decisions about you, please contact our Privacy Officer in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.
We may deny your request in certain limited situations, such as when research is in progress. If we do, we will advise you in writing in a timely manner of our reasons for the denial and information on how you may have the denial reviewed. We will comply with the outcome of any such review.
The Right To Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose for treatment, payment, or health care operations. You may not limit the uses and disclosures that we are legally required or allowed to make. You also have the right to request a limit on medical information we disclose about you to someone who is involved in your care, like a family member or friend. To request restrictions on the use or disclosure of your medical information, you may do so when you register, or at any time by contacting our Privacy Officer. Your request must include 1) what information you want to limit, 2) whether you want to limit our use, disclosure, or both, and 3) to whom you want the limits to apply (for example, disclosures to your spouse). A previously agreed to restriction may be terminated by you or by Velona Health PLLC in writing. If we terminate the restriction, we can only use or disclose medical information we create or obtain after the restriction is removed.
We May Deny Your Request: Velona Health PLLC will review any request to limit the disclosure of your health-related information on a case-by-case basis. We will not treat you until this review has been made and we have agreed to the request. If we do agree to your request, we will comply with it unless the information is needed to provide you emergency treatment.
The Right To Amend: If you believe that medical information we have about you is incorrect or incomplete, you have the right to request that we correct the existing information or add the missing information. You have the right to request the amendment for as long as the information is kept by Velona Health PLLC. To request an amendment, you must provide the request in writing along with the reason for the request to our Privacy Officer. We will respond within 60 days of your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if the medical information is 1) correct and complete, 2) not created by us, 3) not allowed to be disclosed, or 4) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you file a written statement of disagreement, you have the right to request that your request and our denial be attached to all future disclosures of your personal health information. If we approve your request, we will make the change to your personal health information, tell you that we have done it, and tell others that need to know about the change in your personal health information.
The Right To Accounting Of Disclosures: You have the right to request an ‘‘accounting of disclosures’’. This is a list of instances in which we have disclosed medical information about you, with certain exceptions specifically defined by law. The list will not include certain uses or disclosures, such as those you have specifically authorized and those that are otherwise permitted, such as ones made for treatment, payment, or health care operations, directly to you, or to your family. To request this accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period. The first list you request within a 12-month period will be free-of-charge. Subsequent lists during the same year will incur a charge for the cost of providing the list. You may choose to withdraw or modify your request at that time before any costs are incurred. We will respond within 60 days of receiving your request. We will notify you in writing if we need an additional 30 days to respond. The list we will give you will include the date of each applicable disclosure, to whom the information was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure.
The Right To Request Confidential Communications: You have the right to ask that we send information to you to an alternate address (for example, if you want appointment reminders to not be left on an answering machine or if you want information sent to your work address rather than your home address). We will agree to all reasonable requests so long as we can easily provide it in the format you requested. To request that medical information be sent to an alternative address or by other means, please contact our Privacy Officer.
The Right To a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice at any time. To obtain a paper copy of this notice, please contact the person listed below.
CONCERNS AND COMPLAINTS
If you believe that we may have violated your rights with respect to your medical information, you may contact our Privacy Officer. You may also file a complaint to the US Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints within 180 days of an alleged violation of your rights. You will not be penalized for filing a complaint about our privacy practices. You will not be required to waive this right as a condition of treatment.
CHANGES
We reserve the right to change the terms of this Notice and our privacy policies at any time. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.
If you have any questions, please contact our Privacy Manager:
Dr. CJ Mimee, PT, DPT, RYT
Velona Health PLLC
1525 E. 53rd Street, Suite 627, Chicago, IL 60615
Call: 312-324-0953
Fax: 312-324-0958
drmimee@velonahealth.com