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.
Midwest NeoPed acts to maintain the privacy of protected
health information and provide individuals with notice of
Midwest NeoPed’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
Provision of Notice: Midwest NeoPed 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.
Midwest NeoPed makes its Notice available to any member of
the public to enable prospective patients to evaluate Midwest
NeoPed’s privacy practices when making his or her decision
regarding whether to seek treatment from Midwest NeoPed. Midwest
NeoPed provides its Notice via e-mail to any patient or other
individual who so requests the Notice.
Documentation of Provision of Notice: When
a direct treatment patient receives the Notice from Midwest
NeoPed, Midwest NeoPed 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. Midwest NeoPed 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, Midwest NeoPed makes the revised
Notice available upon request beginning on the revision’s
effective date. The revised notice is posted in Midwest NeoPed’s
reception area and made available to all patients, including
those who have received a previous Notice. Upon receipt of
a revised Notice, a patient is asked to acknowledge receipt
of the Notice.
Complaints: Midwest NeoPed allows all patients
and their agents to file complaints with Midwest NeoPed 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 Midwest NeoPed whenever he or she believes
that Midwest NeoPed has violated their rights.
Complaints to Midwest NeoPed 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 Midwest NeoPed’s
privacy officer at Midwest NeoPed’s address. Midwest
NeoPed 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 Midwest NeoPed,
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: U.S. Department
of Health and Human Services, 200 Independence Avenue, S.W.,
Washington DC, 20201 or telephone 1-202-619-0257 or at http://www.hhs.gov/about/referlst.html.
Midwest NeoPed does not take any adverse action against any
patient who files a complaint (either directly or through
an agent) against Midwest NeoPed.
Contact Person: Midwest NeoPed
has a privacy officer that serves as the contact person for
all issues related to the Privacy Rule. The privacy officer
is MaryAnn Greene. If you have any questions about this Notice,
please contact MaryAnn Greene at 630-654-6700 or 900 Jorie
Boulevard, Suite 186, Oak Brook Illinois 60523.
USES AND DISCLOSURES
OF PROTECTED HEALTH INFORMATION
Midwest NeoPed reasonably ensures that the protected
health information (PHI) it requests, uses, and discloses
for any purpose is the minimum amount of PHI necessary for
Midwest NeoPed treats all qualified individuals as personal
representatives of patients. Midwest NeoPed 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.
Midwest NeoPed 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
Uses and Disclosures – Treatment, Payment, and Health
Midwest NeoPed 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 includes 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: Midwest NeoPed 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 Midwest NeoPed.
When the patient is not present, Midwest NeoPed 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.
Midwest NeoPed 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, Midwest NeoPed uses and discloses
information as required by law.
Uses and Disclosures Required by Law: Midwest NeoPed
uses and discloses protected health information to appropriate
individuals as required by law.
As required by law Midwest NeoPed 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,
Midwest NeoPed discloses protected health information regarding
victims of abuse, neglect, or domestic violence. Midwest NeoPed
discloses information about a minor, disabled adult, nursing
home resident, or person over 60 years of age whom Midwest
NeoPed 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
Midwest NeoPed informs the individual of the reporting unless
Midwest NeoPed, in the exercise of professional judgment,
believes informing the individual would place the individual
at risk of serious harm or Midwest NeoPed would be informing
a personal representative, and Midwest NeoPed 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 Midwest NeoPed.
Uses and Disclosures for Health Oversight Activities:
Midwest NeoPed 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, Midwest NeoPed 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:
Midwest NeoPed discloses PHI for law enforcement purposes
to law enforcement officials.
Uses and Disclosures Related to Decedents:
Midwest NeoPed 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: Midwest NeoPed uses and discloses
protected health information to facilitate organ, eye or tissue
Uses and Disclosures to Avert a Serious Threat to
Health or Safety: Midwest NeoPed uses and discloses
protected health information to public health and other authorities
as required by law to avert a serious threat to health or
Uses and Disclosures for Specialized Government Functions:
Midwest NeoPed uses and discloses protected health information
for military and veteran’s activities, national security
and intelligence activities, and other activities as required
Uses and Disclosures in Emergency Situations:
Midwest NeoPed uses and discloses protected health information
as appropriate to provide treatment in emergency situations.
In those instances where Midwest NeoPed has not previously
provided its Notice of Privacy Practices to a patient who
receives direct treatment in an emergency situation, Midwest
NeoPed provides the Notice to the individual as soon as practicable
following the provision of the emergency treatment.
Marketing Purposes: Midwest NeoPed does not
use or disclose any protected health information for marketing
purposes. Midwest NeoPed 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. These
activities are not considered marketing.
In addition, Midwest NeoPed will contact the individual with
appointment reminders or information about treatment alternatives
or other heath-related benefits and services that may be of
interest to the individual.
Uses and Disclosures – Do Not Apply to Practice
Research: Midwest NeoPed does not engage
in any research activities that require it to use or disclose
protected health information.
Other Uses and Disclosures: Midwest NeoPed
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 Midwest NeoPed 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 Midwest
NeoPed and complete an appropriate written authorization.
Individual Rights – Accounting for Disclosures of Protected
Midwest NeoPed 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.
Midwest NeoPed allows an individual to request one accounting
within a 12-month period free of charge. Midwest NeoPed charges
a reasonable fee for more frequent accounting requests. The
charge will be $20.00. 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.
Midwest NeoPed responds to all requests for an accounting
of disclosures within 60 days of receipt of the request. If
Midwest NeoPed intends to provide the accounting for disclosures
and cannot do so within 60 days, Midwest NeoPed 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 Midwest NeoPed.
It should be marked “Attention: Privacy Officer.”
Individual Rights – Inspect and Copy Protected Health
Midwest NeoPed 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
Midwest NeoPed reviews the request in a timely
fashion and acts on a request for access generally within
30 days. Midwest NeoPed 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 eligible for review or not. The requestor has the right
to have any denial reviewed by a licensed health care professional
who is designated by Midwest NeoPed as a reviewing official
and who did not participate in the original decision to deny.
Midwest NeoPed informs the requestor of the decision of the
reviewing official and adheres to the decision.
Midwest NeoPed charges reasonable fees based on actual cost
of fulfilling the request. Midwest NeoPed 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. Midwest NeoPed limits charges for records
to the amounts allowed under Illinois law.
Requests for the inspection and copying of records must be
sent to Midwest NeoPed in writing. It should be marked “Attention:
Individual Rights – Request Amendment to
Protected Health Information
Midwest NeoPed allows an individual to request that Midwest
NeoPed amend the protected health information maintained in
the patient’s medical record or the patient’s
billing record. Midwest NeoPed 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
Generally Midwest NeoPed will act on a request for amendment
no later than 60 days after receipt of such a request. If
Midwest NeoPed cannot act on the amendment within 60 days,
Midwest NeoPed 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 Midwest NeoPed will complete action on the
request. Only one such extension is allowed.
If Midwest NeoPed denies the request, in whole or in part,
Midwest NeoPed provides the requestor with a written denial
in a timely fashion. Midwest NeoPed 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. Midwest NeoPed limits the length
of a statement of disagreement to one page.
Midwest NeoPed accepts requests to amend the PHI maintained
by Midwest NeoPed. The requests must be in writing and should
be marked “Attention: Privacy Officer.”
Individual Rights – Request Confidential
Midwest NeoPed accommodates all reasonable requests to keep
communications confidential. Midwest NeoPed 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 Midwest NeoPed’s privacy
officer. No reason for the request needs to be stated.
Midwest NeoPed accommodates all reasonable requests. The reasonableness
of a request is determined solely on the basis of the administrative
difficulty of complying with the request. Midwest NeoPed 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.
Midwest NeoPed 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
Individual Rights – Request Restriction of Disclosures
Midwest NeoPed accepts all requests for restrictions of disclosures
of protected health information. Midwest NeoPed does not agree
to any restrictions in the use or disclosure of protected
All requests for restrictions of disclosures must be submitted
in writing. They must be sent to the attention of Midwest
NeoPed’s privacy officer. The privacy officer notifies
the requestor in writing that Midwest NeoPed does not accept
restrictions of disclosure.
Individual Rights – Authorizations
Midwest NeoPed 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, Midwest NeoPed
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. Midwest NeoPed
will provide a patient upon request a copy of any authorization
initiated by Midwest NeoPed (as opposed to requested by the
patient) and signed by the patient.
Midwest NeoPed 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.
Midwest NeoPed allows an individual to revoke an authorization
at any time. The revocation must be in writing and must be
sent to the attention of Midwest NeoPed’s privacy officer;
however, in any case Midwest NeoPed 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
Midwest NeoPed 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