Consent And Acknowledgment (Page 3 of 4) in pdf

treatment, payment and health care operations. We are not required to agree to your request.

Communications: You have a right to receive confidential communications about your PHI. For

example, you may request that we only call you at home. If your request is reasonable, we will

accommodate it.

Inspect and Access: You have a right to inspect information used to make decisions about your

care. This information includes billing and medical record information. You may not inspect

your record in some cases. If your request to inspect your record is denied, we will send you a

letter letting you know why and explaining your options.

You may copy your PHI in most situations. If you request a copy of your PHI, we may charge

you a fee for making the copies and mailing them to you, if you ask us to mail them.

Amendments of your Records: If you believe there is an error in your PHI, you have a right to

request that we amend your PHI. We are not required to agree with your request to amend.

Accounting of Disclosures: You have a right to receive an accounting of disclosures that we have

made during the previous six years (but the request cannot include dates before April 14, 2003) of

your PHI for purposes other than treatment, payment, and health care operations, or release made

pursuant to your authorization.

Copy of Notice: You have a right to obtain a paper copy of this Notice, even if you originally

received the Notice electronically. We have also posted this Notice at the health department

offices and other service delivery sites.

Complaints: If you feel that your privacy rights have been violated, you may file a complaint

with the health department in writing at the following address: Attn: Privacy Officer, Kane

County Health Department, 210 S. Sixth St., Geneva, IL 60134. You may also file a complaint

with the Secretary of Health and Human Services in Chicago, IL, or via email, if you feel your

privacy rights have been violated. To obtain further information on how to file a complaint with

either entity, you may call Claire Dobbins, Privacy Officer, at (630)208-3801. We will not

retaliate against you for filing a complaint.

We maintain a facility directory so that if family or friends ask us about your condition, we can tell them

general information and the fact that you are here. If you do not want us to tell anyone you are here,

please tell us now.

We are required to abide with terms of the Notice currently in effect. However, we may change this

Notice. If we materially change this Notice, you can get a revised Notice on our website at www.

, or by stopping by our office to pick up a copy. Changes to the Notice are applicable to

the health information we already have.

If we seek help from individuals or entities who are not part of this Notice in our treatment, payment, or

health care operations activities, we will require the those persons to follow this Notice unless they are

already required by law to follow the federal privacy rule.

If you would like any further information concerning this form or the Health Department’s privacy

practices, please contact Claire Dobbins, Privacy Officer, at (630) 208-3801.

EFFECTIVE DATE: April 14, 2003

Notice of Privacy Practices

Kane County Health Department, Kane County, IL

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