Consent And Acknowledgment (Page 2 of 4) in pdf

Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant

to a court order, warrant, subpoena, summons, or similar process. We may use and disclose PHI

to locate someone who is missing, to identify a crime victim, to report a death, to report criminal

activity at our offices, or in an emergency.

Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or

someone else from getting hurt.

Work-Related Injuries: We may use or disclose PHI to an employer if the employer is conducting

medical workplace surveillance or to evaluate work-related injuries.

Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or

medical examiner in some situations. For example, PHI may be needed to identify a deceased

person or determine a cause of death. Funeral directors may need PHI to carry out their duties.

Armed Forces: We may use or disclose the PHI of Armed Forces personnel to the military for

proper execution of a military mission. We may also use and disclose PHI to the Department of

Veterans Affairs to determine eligibility for benefits.

National Security and Intelligence: We may use or disclose PHI to maintain the safety of the

President or other protected officials. We may use or disclose PHI for the conduct of national

intelligence activities.

Correctional institutions and custodial situations: We may use or disclose PHI to correctional

institutions or law enforcement custodians for the safety of individuals at the correctional

institution, those that are responsible for transporting inmates, and others.

Organ, Eye or Tissue Donation: We may disclose your health information to people involved

with obtaining, storing or transplanting organs, eyes or tissue of cadavers for donation purposes.

Research: You will need to sign an Authorization form before we use or disclosure PHI for

research purposes except in limited situations. For example, if you want to participate in research

or a clinical study, an Authorization form must be signed.

Fundraising:

If we undertake any fundraising activities, we may contact you about the

fundraising activity. We do not engage in marketing activities, and need your authorization to do

so.

Illinois law: Illinois law also has certain requirements that govern the use or disclosure of your PHI. In

order for us to release information about mental health treatment, genetic information, your AIDS/HIV

status, and alcohol or drug abuse treatment, you will be required to sign an authorization form unless state

law allows us to make the specific type of use or disclosure without your authorization.

If you sign an authorization form, you may withdraw your authorization at any time, as long as your

withdrawal is in writing. If you wish to withdraw your authorization, please submit your written request

to: Privacy Officer, Kane County Health Department, 210 S. Sixth St., Geneva, IL 60134.

Your Rights: You have certain rights under federal privacy laws relating to your PHI. Some of these

rights are described below:

Restrictions: You have a right to request restrictions on how your PHI is used for purposes of

Notice of Privacy Practices

Kane County Health Department, Kane County, IL

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