Your Privacy

The importance of your privacy

Our Pledge Regarding Health Information

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive from us because we need this record to provide you with quality care and to comply with certain legal requirements. This notice tells you about the ways we may use and share medical information about you. It also describes your rights and certain duties we have regarding the use and disclosure of medical information.

  1. Use and disclosure of your medical information

The following section describes different ways we are permitted to use and disclose medical information. Not every use or disclosure is listed, but each use or disclosure falls into one of these categories. Any use or disclosure of your medical information for any purpose not listed below requires a written consent from you. You may submit a written request to revoke consent at any time.

For Treatment:

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or others who are involved in your care. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.

For payment

We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your insurance company information about your office visit so your insurance plan will pay us or reimburse you for the visit.

For healthcare operations

The use and disclosure of health care information may be necessary to run our practice and make sure that all our patients receive quality care. For example, we may use health information to evaluate the performance of our staff in caring for you. We may also use information for accreditation, certificates, licenses, and credentials we need to serve you.

Additional uses and disclosures

In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purpose:

  • Purpose example
    • As required by law to avert a serious threat to health/safety
    • Disaster Relief Specialized government functions (military and veterans)
    • Workers’ Compensation Court orders, judicial and administrative proceedings
    • Public health risks Victims of abuse, neglect or domestic violence
    • Health oversight activity Law enforcement
  1. Your Individual Rights

You have a right to inspect and copy your medical information.

Request for copies of medical information must be in writing to the attention of Medical Records. Please allow two weeks for processing. We will request that you complete our release form and pay a fee of $10.00 to cover the cost of copying the records.

You have the right to amend your information.

If you feel that your health information is incorrect or incomplete, you may request an amendment by writing to the privacy officer listed below. You must provide a reason that supports your request.

You have the right to an accounting of disclosers.

You may request a listing of disclosures of your health information made for purposes other than treatment, payment, or operations. Your request must be submitted per directions below.

You have the right to request restrictions on information released.

For example, you could ask that we not disclose information to your spouse about a surgery you had. We are not required to agree to your request if we feel it will have a negative impact on your care. If we do agree, we will abide by your agreement. Your request must be submitted per directions below.

You have the right to request confidential communications.

You may request that we communicate with you about health matters in a certain way or at a certain locations. For example, you may ask that we only contact you at work. Your request must be submitted per directions below.

NOTE: All requests for information or other specific request must be in writing and directed to Patricia Sulaver RN, the Privacy Officer, at the address listed in #4 below. Please allow 14 days for a response.

  1. Our Legal Duty 
  • We are legally required to: Keep your medical information private, provide you with this notice regarding our legal duties, privacy practices, and your rights regarding your medical information. Follow the terms of this notice that is now in effect.
  • We have the right to: Change our privacy practices and the terms of this notice at any time, provided the changes are permitted by law. Make the changes effective for all medical information that we keep, including information previously created or received before the change.
  • We will: Make any changes in our privacy practices available upon request before we implement them.
  1. Questions and Complaints

Please address questions or complaints to: Patricia Sulaver RN, Midland Surgical Center, 2120 Midlands Court, Sycamore, IL 60178, (815) 748-0393.

If you think that we may have violated your privacy rights, contact the person named above. You may also submit a written complaint to the US Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.