Policies and Disclaimers
Right to Receive a Good Faith Estimate of Expected Charges Notice
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (312) 677-3775.
Notice of Privacy Practice
Your Information. Your Rights. Our Responsibilities.
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.
YOUR RIGHTS: You have the right to:
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
YOUR CHOICES: You have some choices in the way that we use and share information as we:
Tell family and friends about your condition
Provide disaster relief
Provide mental health care
OUR USES & DISCLOSURES: We may use and share your information as we:
Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Work with a coroner/medical examiner
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
OUR RESPONSIBILITIES
We are required by law to maintain the privacy and security of your protected health information. We will not use or disclose your health information other than as described here unless you provide written authorization. You may revoke your authorization at any time, in writing, but only as to future uses or disclosures and only where we have not already acted in reliance on your authorization. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Please feel free to contact our Privacy Officer with any questions.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Right to Inspect & Request an Electronic or Paper Copy of Your Medical Record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Right to Request a Correction to Your Medical Record
You can ask us to correct health information about your protected health information that you think is incorrect or incomplete, as long as the information is kept by or for us.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Right to Request Confidential Communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will meet all reasonable requests.
Right to Request a Restriction on Certain Uses and Disclosures
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information relating solely to that item or service for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Right to Obtain an Accounting of Disclosures of Your Health Information
You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Right to Obtain a Copy of this Notice of Privacy Practices
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Right to Receive Notice of a Breach
You have the right to be notified in writing following a breach of your health information that was not secured in accordance with security standards as required by law.
Right to Choose Someone to Act for You
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
Right to File a Complaint
You can complain if you feel we have violated your rights by contacting Dr. David Meyerson or Lee Dal Pra.
You also have to right to file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Room 509F, Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
OUR USES & DISCLOSURES
How do we typically use or share your health information? We may use and share your health information for the following purposes:
Treatment: We may use and disclose your health information to provide treatment, and to coordinate care, or manage your healthcare and any related services by sharing it with other professionals, an integrated health system, or a member of an interdisciplinary team who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run Our Organization/Healthcare Operations: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We may use your health information to conduct quality assessment and improvement activities.
Payment: We can use and share your health information, as needed, to bill and obtain payment for our health care services from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
Business Associates: We may disclose your health information to our third-party business associates (for example, a billing company or accounting firm) that performs activities or services on our behalf. Business associates must agree in writing to protect the confidentiality of your information. Example: We may use or disclose your health information to a business associate that we use to provide reminders to you of an upcoming appointment.
How else can we use or share your health information? We may be allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. The following are other uses and disclosures we make of your health information without your authorization, consent or opportunity to object: (For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html)
Required by Law: We may share information about you to the extent that is required by state, federal or local laws under the circumstances provided by such law; this includes with the Department of Health and Human Services if it wants to see that we are complying with the federal privacy law.
Health Oversight Activities: We may use and disclose your health information to state agencies and federal government authorities, or to a health oversight agency, for activities authorized by law such as audits, administration or criminal investigations, inspections, licensure, accreditation or disciplinary action and monitoring compliance with the law, including in order to determine your eligibility for public benefit programs and to coordinate delivery of those programs. The Illinois Mental Health and Developmental Disabilities Confidentiality Act allows for the unconsented disclosure of your health information to a health information exchange (HIE), which oversees the electronic exchange of health information, for HIE purposes. See 740 ILCS 110/9.5.
Public Health & Safety: We may use or disclose your health information in certain situations, such as in order to prevent/report communicable diseases, helping with product recalls, reporting adverse reactions to medications, to prevent or reduce a serious threat to anyone’s health or safety, and for work place surveillance or work related illness and injury.
Research: We may disclose your health information for research.
Worker’s Compensation, Law Enforcement, & Other Governmental Requests: We may disclose your health information as authorized to comply with worker’s compensation claims, for law enforcement purposes or with a law enforcement official, and for special government functions, such as military, national security and presidential protective services.
Abuse, Neglect or Domestic Violence: We may disclose your health information to the designated public agency that is authorized by law to receive reports of child or elder abuse, neglect, or domestic violence. This disclosure will be made consistent with the requirements of applicable federal and state laws.
Coroner/Medical Examiner: We may disclose your health information to a coroner/medical examiner for an investigation of a death and/or homicide, identification purposes, determining cause of death or for the coroner to perform other duties authorized by law.
Lawsuits & Legal Proceedings: We can share health information about you in response to a valid court or administrative order, or in response to a subpoena, to the extent that such disclosure is authorized and permissible under the Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/1 et seq.
YOUR CHOICES
Your Choice. For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please let us know. If you are not able to tell us your preference, we may share your information if we believe it is in your best interest. In the following cases, you have the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
If your health information is accessible through the HIE, you may provide a written request to opt-out of further disclosure by the HIE to third parties, except to the extent permitted by law (See www.hie.illinois.gov for information on opting-out)
Written Authorization. Any other uses and disclosures of your health information not described in this Notice will be made only with your authorization. Disclosures requiring your written authorization include:
Subject to exceptions, uses and disclosures of your health information for marketing purposes
Disclosures that constitute a sale of your health information
Most uses and disclosures of psychotherapy notes.
OTHER INFORMATION
Changes to the Terms of this Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. The effective date of this Notice of Privacy Practices is August 1, 2019.
Other Instructions for Notice: We further comply with the following state and federal laws and regulations related to the disclosure of your protected health information:
Mental Health Records Disclosure: We comply with the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/1 et seq.
Alcohol/Substance Abuse Records Disclosure: We comply with the federal Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 et seq. If any requested records contain information regarding alcohol or drug abuse treatment, these records are protected by Federal confidentiality rules, and such information is prohibited from further disclosure without express permission by written consent of the person to whom it pertains or as otherwise permitted by Federal Rules. A general authorization for the use or release of medical or other information is insufficient for this purpose. Federal rules restrict use of the information for criminal investigation or prosecution of any alcohol or drug abuse patient. See 42 U.S.C. § 290dd-3 and § 290ee-3; 42 C.F.R. Part 2 et seq.; and 20 ILCS 301 et seq.
This Notice of Privacy Practices applies to the following entities: This Notice of Privacy Practices applies to Mind Chicago, P.C., including staff, administrators, employees, agents, and board members, in Chicago, Illinois.
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