UNDERSTANDING YOUR HEALTH INFORMATION AND MEDICAL RECORD
Each time you visit a hospital, physician, or other healthcare provider, they document information about you and your visit. Typically, this record is referred to as your medical record and contains your name, symptoms, health history and exam, test results, diagnoses, treatment given and a plan for future care or treatment (“Health Information”). This medical record is used to plan your care and treatment and be a source of your health information as described below.

YOUR HEALTH INFORMATION RIGHTS
Your medical record is the physical property of the Golf Surgical Center, however the information within your medical record belongs to you. Federal and Illinois Laws provide you with the following rights regarding your health information that is contained in the medical record that Golf Surgical Center keeps about you.

Right to obtain a copy of this Notice of Privacy Practices. Right to request certain restrictions on the uses and disclosures of your health information. Right to inspect or receive a copy of your health record. Right to request an amendment to your health record if you believe it contains an error. Right to obtain a list of all the people and companies to which GOLF SURGICAL CENTER has released your health information (an “accounting” of disclosures). Right to request that we communicate with you about your health care at a confidential phone number or address. Right to revoke your written consent/authorization to use or disclose your health information except when the use or disclosure has already happened.

Federal and Illinois laws also provide you with the right to be informed about and give your written authorization before any health information, including Highly Confidential Information, is disclosed, unless such disclosure is allowed or required by law. Examples of Highly Confidential Information are mental health treatment information, substance abuse prevention, treatment or referral; developmental disability services; HIV/AIDS testing and treatment, venereal disease treatment, sexual assault treatment, and testing and treatment for genetic disorders.

GOLF SURGICAL CENTER’S RESPONSIBILITIES ARE TO

Maintain the privacy of your health information as required by law. Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. Do what is required by this Notice or a Notice that is in effect at the time Golf Surgical Center uses or discloses your health information. Notify you if we are unable to agree to your requested restriction on disclosure of your health information. Agree to reasonable requests to communicate your health information by an alternative method or at an alternative location.

We reserve the right to change our privacy practices and to use a new Notice of Privacy Practices for all health information we maintain about you and other patients. If Golf Surgical Center changes its practices, a new Notice of Privacy Practices will be available upon your request, by mail or in person at this site.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
Golf Surgical Center will use and disclose your health information contained within the Golf Surgical Center medical record to give you treatment, obtain payment for your treatment and operate our healthcare businesses.

EXAMPLES OF HOW YOUR HEALTH INFORMATION WILL BE USED OR DISCLOSED FOR TREATMENT, PAYMENT AND OPERATIONS.

We will use your health information for treatment.

For example:

Your physician, nurse or other members of your healthcare team will collect and document information about you in your medical record. We may disclose information to a physician or other health care provider who will be assuming your care, for immediate continuity of care. This health information will used to choose the treatment they believe is best for you. Nurses and other members of the team will document in your medical record the actions they took and their observations made of you. Your physician will then know how you are responding to the chosen treatment.

We will use your health information for payment.

For example:

We will send a bill that includes some of your health information to you, to the person responsible for the bill and your third party payer (such as your health insurance company or Medicare). In some instances, we may need to send a copy of part or all of your medical record to your third party payer. The type of health information we will send includes your name, other identifying information, diagnosis, treatment, procedures performed and supplies provided during your treatment.

We will use you health information for our routine operations.

For example:

Physicians, nurses and quality improvement professionals will use your health information to review the treatment you received and it’s outcomes. They may also compare your treatment and outcomes to those of other patients like you. We compare cases to help us continually improve the quality and effectiveness of our healthcare services.

OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION

Upon receipt of your written authorization to use and/or disclose your health information.
We will use and/or disclose your health information to those persons or companies for which you give us your written authorization or permission to do so. If you authorize us to use or disclose your information, you must complete our Release of Health Information Form. You may revoke your authorization in writing at any time except to the extent that we have already used or disclosed your health information as you previously authorized. If your health information includes Highly Confidential Information, we may only use and disclose such information for treatment, payment and operations as described above. Otherwise, unless a disclosure is allowed or required by federal or Illinois law, you must give us your written authorization to disclose your Highly Confidential Information. A person who can verify your identity must witness and co-sign an Authorization to Release Health Information form about treatment for a mental illness or developmental disability

for the purposes described below.
Business Associates. We provide some services through other persons or companies that need access to your health information to carry out these services. The law refers to these persons or companies as our Business Associates. Examples of these Business Associates include billing and record copying companies that assist us with billing for our services or copying medical records. Other types of business associates are organizations that collect information about patients who have been treated with similar problems such as cancer or trauma. These organizations list the information in registry directories that help physicians throughout Illinois to improve the quality of care for other patients with these same problems. We may disclose your health information to our Business Associates so that they can do the job we have contracted with them to do. We require that they use appropriate safeguards to ensure the privacy of your health information.

Health Oversight Activities and Specialized Government Functions. We may disclose your health information to an agency that oversees healthcare systems and ensures compliance with the rules of government health programs such as Medicare or Medicaid; under certain circumstances to the U.S. Military or U.S. Department of State.

Law Enforcement Officials, Medical Examiners and Coroners and Court or Administrative Orders. We may disclose your health information to the police, other law enforcement officials, medical examiners and coroners, and to the courts or administrative proceedings as allowed or required by law, or required by a court order or other legal process.

Notification and Other Communications with Your Relatives, Close Friends or Caregivers. You or your legal representative must tell your physician, nurse or other healthcare team members which of your relatives or other persons may receive information about you. After learning who these persons are, we may, in our best judgment, use and disclose your health information, except for your Highly Confidential Information, to notify these person(s) of what they need to know to care for you. In an emergency or other situation where you are not able to identify your chosen person(s) to receive communications about you, we may exercise our professional judgment to determine whether such a disclosure is in your best interest, who is the appropriate person(s) and what health information is relevant to their involvement with your healthcare.

Public Health Activities. We may report your identity and other health information to: public health authorities for the purpose of controlling disease, injury or disability; to the U.S. Food and Drug Administration for regulating certain products or activities; to governmental authorities about suspected or known child abuse and neglect, elder adult abuse and neglect, or domestic violence; to a person exposed to a contagious disease or has the risk of contracting or spreading a disease; to your employer and governmental agencies as required by federal and state laws regarding work-related illness or injury; to prevent or lessen a serious or imminent threat to a person’s or the public’s health or safety; or, to a public or private entity that is authorized to assist in disaster relief efforts.

Research. We may use or disclose your health information to identify you as a potential candidate for a research study that has been approved by an Institutional Review Board or for governmental research studies in which your identifiable information will not be released.

Workers Compensation. We may disclose your health information as allowed or required by Illinois law relating to workers’ compensation or to other similar programs.

Other Communications with You. We may contact you to remind you of appointments with your physicians or other healthcare team members and to follow up on the services you received. We may leave messages about appointments or other reminders on your telephone or with a person who answers the phone. Unless you notify your nurse or registration coordinator that you object, we may also contact you about other health care services we offer that may benefit you.



ADDITIONAL EXAMPLES OF HOW YOUR HEALTH INFORMATION WILL BE USED OR DISCLOSED



RIGHT TO FILE A COMPLAINT.
If you would like to report a Privacy Problem or want further information, PLEASE CONTACT: