Consent And Acknowledgment printable pdf download

NOTICE OF PRIVACY PRACTICES

Kane County Health Department

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.

The Health Department creates a medical record of your health information in order to treat you, receive

payment for services delivered, and to comply with certain policies and laws. The uses and disclosures

described in this Notice are applicable to the health department. This Notice does not apply to service

providers who are not part of the health department.

We are required by federal and state law to maintain the privacy of your PHI. We are also required by

law to provide you with this Notice of our legal duties and privacy practices. In addition, the law requires

us to ask you to sign an Acknowledgment that you received this Notice.

This is a list of some of the types of uses and disclosures of PHI that may occur:

Treatment: We obtain medical information about you in treating you. This medical information

is called “protected health information” or “PHI”. Your PHI is used by us to treat you. For

example, we refer to PHI in treating you at the health department. We may also send your PHI to

another physician or counselor to which we refer you for treatment. We may also use your PHI

to contact you to tell you about alternative treatments or other health-related benefits we offer. If

you have a friend or family member involved in your care, we may give them PHI about you.

Payment: We use your PHI to obtain payment for the services that we render. For example, we

send PHI to Medicaid, Medicare, or your insurance plan to obtain payment for our services.

Health Care Operations: We use your PHI for our operations. For example, we may use your PHI

in determining whether we are giving adequate treatment to our clients. From time-to-time, we

may use your PHI to contact you to remind you of an appointment.

Legal Requirements: We may use and disclose your PHI as required or authorized by law. For example,

we may use or disclose your PHI for the following reasons:

Public Health: We may use and disclose your health care information to prevent or control

disease, injury or disability, to report births and deaths, to report reactions to medicines or

medical devices, to notify a person who may have been exposed to a disease, or to report

suspected cases of abuse, neglect or domestic violence.

Health Oversight Activities: We may use and disclose your PHI to state agencies and federal

government authorities when required to do so. We may use and disclose your health information

in order to determine your eligibility for public benefit programs and to coordinate delivery of

those programs. For example, we must give PHI to the Secretary of Health and Human Services

in an investigation into our compliance with the federal privacy rule.

Judicial and Administrative proceedings: We may use and disclose your PHI in judicial and

administrative proceedings. Efforts may be made to contact you prior to a disclosure of your PHI

by the party seeking the information.

Notice of Privacy Practices

Kane County Health Department, Kane County, IL

Page 1

4/03

Consent And Acknowledgment