North Suburban Cardiology Group, Ltd.

Notice of Privacy Practices

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.

North Suburban Cardiology Group, Ltd. (NSCG) acts to maintain the privacy of
protected health information and provide individuals with notice of NSCG's legal
duties and privacy practices with respect to protected health information as
described in this Notice and abide by the terms of the Notice currently in effect,

Provision of Notice: NSCG provides its Notice of Privacy Practices to every
patient with whom it has a direct treatment relationship. The Notice is provided
no later than the date of the first treatment to the patient after April 13,2003.

NSCG makes its Notice available to any member of the public to enable
prospective patients to evaluate NSCG's privacy practices when making his or
her decision regarding whether to seek treatment from NSCG. The Notice is
posted in NSCG's offices and on its web site (www.NSCARDIOLOGY.COM).

Documentation of Provision of Notice: When a direct treatment patient
receives the Notice from NSCG, NSCG asks the patient to sign its "Receipt of
Notice of Privacy Practices" form. The form is filed with the patient's medical
record. If the patient refuses to sign the form, it is noted in the medical record
that the patient was given the Notice and refused to sign the form.

Effective Date and Changes to Notice: This Notice is effective April 13, 2003.
NSCG reserves the right to revise this Notice whenever there is a material
change to the uses or disclosures, the individual's rights, the covered entity's
legal duties, or other privacy practices stated in the Notice. Except when
required by law, a material change to any term of the Notice will not be
implemented prior to the effective date of the notice in which such material
change is reflected.

If the Notice is revised, NSCG makes the revised Notice available upon request
beginning on the revision's effective date. The revised notice is posted in
NSCG's reception area and made available to all patients, including those who
have received a previous Notice.

Complaints: NSCG allows all patients and their agents to file complaints with
NSCG and with the Secretary of the federal Department of Health and Human
Services (DHHS). A patient or his or her agent may file a complaint with NSCG
whenever he or she believes that NSCG has violated their rights.

Complaints to NSCG must be in writing, must describe the acts or omissions that
are the subject of the complaint, and must be filed within 180 days of the time the
patient became aware or should have become aware of the violation.
Complaints must be addressed to the attention of NSCG's privacy officer at
NSCG's address. NSCG investigates each complaint and may, at its discretion,
reply to the patient or the patient's agent.

Complaints to the Secretary of the Department of Health and Human Services
must be in writing, must name NSCG, must describe the acts or omissions that
are the subject of the complaint, and must be filed within 180 days of the time the
patient became aware or should have become aware of the violation.
Complaints must be addressed to:

Department of Health & Human Services
200 Independence Ave. S.W.
Washington, D.C. 20201

NSCG does not take any adverse action against any patient who files a
complaint (either directly or through an agent) against NSCG.

Contact Person: NSCG has a privacy officer that serves as the contact person
for all issues related to the Privacy Rule. The privacy officer is Mrs. I. Goodman.
If you have any questions about this Notice, please contact Mrs. I. Goodman at
847-866-6600 or 800 Austin, Suite 408, Evanston, IL 60202.

 

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

NSCG reasonably ensures that the protected health information (PHI) it requests,
uses, and discloses for any purpose is the minimum amount of PHI necessary for
that purpose.

NSCG treats all qualified individuals as personal representatives of patients.
NSCG generally allows individuals to act as personal representatives of patients.
The two general exceptions to allowing individuals to act as personal
representatives relate to unemancipated minors and abuse, neglect, or
endangerment situations.

NSCG makes reasonable efforts to ensure that protected health information is
only used by and disclosed to individuals that have a right to the protected health
information. Toward that end, that practice makes reasonable efforts to verify the
identity of those using or receiving protected health information.

Uses and Disclosures - Treatment Payment, and Health Care Operations

NSCG uses and discloses protected health information for payment, treatment,
and health care operations. Treatment includes those activities related to
providing services to the patient, including releasing information to other health
care providers involved in the patient's care. Payment relates to all activities
associated with getting reimbursed for services provided, including submission of
claims to insurance companies and any additional information requested by the
insurance company so they can determine if they should pay the claim. Health
care operations
include a number of areas, including quality assurance and peer
review activities.

Uses and Disclosures - Not Requiring Authorization

Disclosure to Those Involved in Individual's Care: NSCG discloses protected
health information to those involved in a patient's care when the patient approves
or, when the patient is not present or not able to approve, when such disclosure
is deemed appropriate in the professional judgment of NSCG.

When the patient is not present, NSCG determines whether the disclosure of the
patient's protected health information is authorized by law and if so, discloses
only the information directly relevant to the person's involvement with the
patient's health care.

NSCG does not disclose protected health information to a suspected abuser, if,
in its professional judgment, there is reason to believe that such a disclosure
could cause the patient serious harm. Further, NSCG uses and discloses
information as required by law.

Uses and Disclosures Required by Law: NSCG uses and discloses protected
health information to appropriate individuals as required by law.

As required by law NSCG discloses protected health information to public health
officials. This includes reporting of communicable diseases and other conditions,
sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated
reports of injury, medical conditions or procedures, or food-borne illness including
but not limited to adverse reactions to immunizations, cancer, adverse pregnancy
outcomes, death, birth.

NSCG discloses protected health information regarding victims of abuse, neglect,
or domestic violence. NSCG discloses information about a minor, disabled adult,
nursing home resident, or person over 60 years of age whom NSCG reasonably
believes to be a victim of abuse or neglect to the appropriate authorities as
required by law or, if not required by law, if the individual agrees to the
disclosure. This includes child abuse and neglect, elder abuse and exploitation,
abused and neglected nursing home residents, or disabled adults abuse.

NSCG informs the individual of the reporting unless NSCG, in the exercise of
professional judgment, believes informing the individual would place the
individual at risk of serious harm or NSCG would be informing a personal
representative, and NSCG believes the personal representative is responsible for
the abuse, neglect, or other injury, and that informing such person would not be
in the best interests of the individual as determined by the professional judgment
of NSCG.

Uses and Disclosures for Health Oversight Activities: NSCG uses and
discloses PHI as required by law for health oversight activities. The information
may be used and released for audits, investigations, licensure issues, and other
health oversight activities, including, but limited to hospital peer review, managed
care peer review, or Medicaid or Medicare peer review.

Disclosures for Judicial and Administrative Proceedings: In general, NSCG
discloses information for judicial and administrative proceedings in response to
an order of a court or an administrative tribunal; or a subpoena, discovery
request or other lawful process, not accompanied by a court order or an ordered
administrative tribunal.

Disclosures for Law Enforcement Purposes: NSCG discloses PHI for law
enforcement purposes to law enforcement officials.

Uses and Disclosures Related to Decedents: NSCG uses and discloses PHI
as required to a coroner or medical examiner and funeral directors as required by
law. The attending physician is required to sign the death certificate and provide
the coroner with a copy of the decedent's protected health information.

Uses and Disclosures Related to Cadaveric Organ, Eye or Tissue
Donations:
NSCG uses and discloses protected health information to facilitate
organ, eye or tissue donations.

Uses and Disclosures to Avert a Serious Threat to Health or Safety: NSCG
uses and discloses protected health information to public health and other
authorities as required by law to avert a serious threat to health or safety.

Uses and Disclosures for Specialized Government Functions: NSCG uses
and discloses protected health information for military and veterans activities,
national security and intelligence activities, and other activities as required by
law.

Uses and Disclosures in Emergency Situations: NSCG uses and discloses
protected health information as appropriate to provide treatment in emergency
situations, in those instances where NSCG has not previously provided its
Notice of Privacy Practices to a patient who receives direct treatment in an
emergency situation, NSCG provides the Notice to the individual as soon as
practicable following the provision of the emergency treatment.

Marketing Purposes: NSCG does not use or disclose any protected health
information for marketing purposes. NSCG does engage in communications
about products and services that encourages recipients of the communication to
purchase or use the product or service for treatment, to direct or recommend
alternative treatments, therapies, health care providers, or settings of care to the
individual.

In addition, NSCG may contact the individual by telephone, mail, or in person
with appointment reminders, test results, personal medical information or
information about treatment alternatives or other health-related benefits and
services that may be of interest to the individual.

Uses and Disclosures

Research: NSCG may engage in research activities that require it to use
protected health information. However, NSCG will not disclose PHI as part of
any research activity.

Other Uses and Disclosures: NSCG does not use or disclose protected health
information to an employer or health plan sponsor, for underwriting and related
purposes, for facility directories, to brokers and agents, or for fundraising.

If an individual wants NSCG to release his or her protected health information to
employers or health plan sponsors, for underwriting and related purposes, for
facility directories, or to brokers and agents, then he or she can contact NSCG
and complete an appropriate written authorization.

 

INDIVIDUAL RIGHTS

Individual Rights - Accounting for Disclosures of Protected Health Information

NSCG tracks all disclosures of a patient's protected health information that occur
for other than the purposes of treatment, payment, and health care operations,
that are not made to the individual or to a person involved in the patient's care,
that are not made as a result of a patient authorization, and that are not made for
national security or intelligence purposes or to correctional institutions or law
enforcement officials. Each patient is entitled to a copy of the list of disclosures of
the patient's PHI.

NSCG allows an individual to request one accounting within a 12-month period
free of charge. NSCG charges a reasonable fee for more frequent accounting
requests. The charge will be $50. An individual can request an accounting of
disclosures for a period of up to six years prior to the date of the request.
Requests for shorter accounting periods will be accepted. However, patients
may only request an accounting of disclosures made on or after April 14,2003.

NSCG responds to all requests for an accounting of disclosures within 60 days of
receipt of the request. If NSCG intends to provide the accounting for disclosures
and cannot do so within 60 days, NSCG informs the requestor of such and
provides a reason for the delay and the date the request is expected to be
fulfilled. Only one 30-day extension is permitted.

A request for an accounting for disclosures must be made in writing and mailed
or sent to NSCG. It should be marked "Attention: Privacy Officer."

Individual Rights - Inspect and Copy Protected Health Information

In the presence of authorized NSCG personnel, NSCG allows individuals to
inspect and copy their protected health information, documents all requests,
responds to those requests in a timely fashion, informs individuals of their appeal
rights when a request is rejected in whole or in part, and charges a reasonable
fee for the copying of records.

NSCG often receives PHI from outside sources, e.g., medical records from other
practices, lab reports, and x-rays. This so-called "secondary record" PHI is
incorporated into the practice's medical records. As such, it becomes part of the
practice's medical records and is not treated differently from the PHI created by
the practice. Accordingly, PHI from outside sources is available for inspection
and copying, regardless of source, in the same manner as the rest of the medical
record.

NSCG reviews the request in a timely fashion and acts on a request for access
generally within 30 days. NSCG may have a single extension of 30 days, if
needed to act on the request. Each request will be accepted or denied and the
requestor notified in writing. If a request is denied, the requestor is informed if
the denial is "renewable" or not. The requestor has the right to have any dental
reviewed by a licensed health care professional who is designated by NSCG as a
reviewing official and who did not participate in the original decision to deny.
NSCG informs the requestor of the decision of the reviewing official and adheres
to the decision.

NSCG charges reasonable fees based on actual cost of fulfilling the request.
NSCG will determine the appropriate charge for providing the requested records
and inform the requestor in advance of providing the records. If the requestor
agrees to pay the fee in advance, the records will be provided. Otherwise, the
records will not be provided, unless the Privacy Officer determines that the
charge is burdensome to the requestor.

Illinois law prohibits charges that exceed the following: $20 handling fee plus 75
cents each for pages 1-25, 50 cents each for pages 26-50, and 25 cents each for
pages 51 to end; plus actual expenses related to the copying of x-rays, CAT
scans, and similar. NSCG limits charges for records to the amounts allowed
under Illinois law.

Requests for the inspection and copying of records must be sent to NSCG in
writing. It should be marked "Attention: Privacy Officer."

Individual Rights - Request Amendment to Protected Health Information

NSCG allows an individual to request that NSCG amend the protected health
information maintained in the patient's medical record or the patient's billing
record. NSCG documents all requests, responds to those requests in a timely
fashion, and informs individuals of their appeal rights when a request is denied in
whole or in part.

Generally NSCG will act on a request for amendment no later than 60 days after
receipt of such a request. If NSCG cannot act on the amendment within 60 days,
NSCG extends the time for such action by 30 days and, within the 60-day time
limit, provides the requestor with a written statement of the reasons for the delay
and the date by which NSCG will complete action on the request. Only one such
extension is allowed.

If NSCG denies the request, in whole or in part, NSCG provides the requestor
with a written denial in a timely fashion. NSCG allows a requestor to submit a
written statement disagreeing with the denial of all or part of the initial request.
The statement must include the basis of the disagreement. NSCG limits the
length of a statement of disagreement to one page.

When accepted, an amendment is appended to the record in question. No
information is ever deleted or altered in an existing record. NSCG accepts
requests to amend the PHI maintained by NSCG. The requests must be in
writing and should be marked "Attention: Privacy Officer." In addition, you may
also appeal this decision to the Secretary, Health and Human Services at:

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave.
Suite 240
Chicago, IL 60601
Voice Phone: 312-686-2359
FAX: 312-886-1807
TDD: 312-353-6693

Individual Rights— Request Confidential Communications

NSCG accommodates all reasonable requests to keep communications
confidential. NSCG determines the reasonableness based on the administrative
difficulty of complying with the request.

A request for confidential communications must be in writing, must specify an
alternative address or other method of contact, and must provide information
about how payment will be handled. The request must be addressed to NSCG's
privacy officer. No reason for the request needs to be stated.

NSCG accommodates all reasonable requests. The reasonableness of a
request is determined solely on the basis of the administrative difficulty of
complying with the request. NSCG will reject a request due to administrative
difficulty: if no independently verifiable method of communication such as a
mailing address or published telephone number is provided for communications,
including billing; or if the requestor has not provided information as to how
payment will be handled.

NSCG will not refuse a request: if the requestor indicates that the communication
will cause endangerment; or based on any perception of the merits of the
requestor's request.

Individual Rights - Request Restriction of Disclosures

NSCG accepts all requests for restrictions of disclosures of protected hearth
information. NSCG does not agree to any restrictions in the use or disclosure of
protected health information.

All requests for restrictions of disclosures must be submitted in writing. They
must be sent to the attention of NSCG's privacy officer. The privacy officer
notifies the requestor in writing that NSCG does not accept restrictions of
disclosure.

Individual Rights — Authorizations

NSCG obtains a written authorization from a patient or the patient's
representative for the use or disclosure of protected health information for other
than treatment, payment, or health care operations; however, NSCG will not get
an authorization for the use or disclosure of protected health information
specifically allowed under the Privacy Rule in the absence of an authorization.
NSCG will provide a patient upon request a copy of any authorization initiated by
NSCG (as opposed to requested by the patient) and signed by the patient,

NSCG does not condition treatment of a patient on the signing of an
authorization, except disclosure necessary to determine payment of claim
(excluding authorization for use or disclosure of psychotherapy notes); or
provision of health care solely for purpose of creating protected health
information for disclosure to a third party (e.g., pre-employment or life insurance
physicals).

In Illinois, a specific written authorization is required to disclose or release of
mental health treatment, alcoholism treatment, drug abuse treatment or
HIV/Acquired Immune Deficiency Syndrome (AIDS) information, even for
treatment. This is an exception to the rule that authorization is not needed to
release PHI for treatment purposes.

Automobile insurance, homeowners insurance, and similar policies that provide
coverage for health care expenditures in most circumstances are not covered
under HIPPA. A signed authorization is required prior to releasing PHI to such
entities.

Worker's compensation also is not covered under HIPPA. However, a signed
authorization usually is not required for release of PHI in worker's compensation
cases. This is because such release of PHI is required by law.

NSCG allows an individual to revoke an authorization at any time. The
revocation must be in writing and must be sent to the attention of NSCG's privacy
officer; however, in any case NSCG will be able to use or disclose the protected
health information to the extent practice has taken action in reliance on the
authorization.

Individual Rights - Waiver of Rights

NSCG never requires an individual to waive any of his or her individual rights as
a condition for the provision of treatment, except under very limited
circumstances allowed under law.

 

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