Notice of Privacy Practices
Your Rights & Our Responsibilities
Effective:
Your Rights
This section explains your rights and how we are required to acknowledge them.
Request a copy of your paper or electronic
medical record
• Upon request, we will supply you with a Request to Inspect or
Copy Patient Information form. The form contains the name of
our privacy offcial and his/her contact information.
• We will provide a copy or a summary of your health information, usually within [30 days] of your request. We may charge a
reasonable fee for cost of labor, postage, and supplies associated
with your request (in compliance with state and federal laws regarding medical records request). We may not charge you a fee
if you require your medical information for a claim for benefts
under the Social Security Act or any other state or federal needsbased beneft program.
Receive a paper copy of this Notice of Privacy
Practices
• You can ask for a paper copy of this notice at any time, even if you
have agreed to receive the notice electronically.
Request correction of your medical record
• Upon request, we will supply you with the Request to Amend
Patient Record form.
• We may deny your request for an amendment if it is not in writing
or does not include a reason to support the request; our response
will be in writing within [60 days].
Request confdential or alternative
communication
• Request that we communicate with you about medical matters in
a certain way or at a certain location. For example, you can ask
that we only contact you at work or by e‐mail.
• Request alternative communications; you must make your request in writing to our privacy offce, a Request for Alternative
Communications form will be provided upon request.
Ask us to limit the information we share
• List individuals who are involved in your care and as a result PHI
can be disclosed; a PHI Use and Disclosure Authorization form
will be provided, upon request.
• Restrict payer access. If you pay for a service or health care item
out-of-pocket in full, you can ask us not to share that information
for the purpose of payment or our operations with your health
insurer. You must make your request in writing to our privacy offce; a Request to Restrict Disclosure to Health Plan form will be
provided upon request.
Receive a list of those with whom we’ve shared
your information
• You have the right to request an accounting of disclosures of your
health information made by us. We are not required to list certain
disclosures, including: disclosures made for treatment, payment,
and health care operations purposes (TPO).
• You must submit your request in writing, a Request for Accounting of Disclosure of PHI form will be provided upon request. The
frst accounting of disclosures (Response to Request for Disclosure form) you request within any 12-month period will be free.
For additional requests within the same period, we may charge
you for the reasonable costs of providing the accounting of disclosures.
Right to Receive Notice of a Breach
• We are required to notify you by frst class mail or by email (if you
have indicated a preference to receive information by e‐mail), of
any breaches of Unsecured Protected Health Information as soon
as possible, but in any event, no later than 60 days following the
discovery of the breach.
File a complaint if you believe your privacy
rights have been violated
• If you believe your privacy rights have been violated, you may
fle a complaint with our privacy offcer; we will supply you with
a Complaint Form upon request (form contains the name of our
privacy offcial and his/her contact information).
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment,
payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. “Protected Health Information” is information about you, including demographic information that may identify
you and that relates to your past, present or future physical health condition and related health care services. Please review it carefully.
Natures Wellness Co
721 W. Lake St., Suite 201, Addison, IL 60101
630-290-3380
December 8, 2017
60 days
60 days• All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known
that the alleged violation occurred.
• You can fle a complaint with the U.S. Department of Health and
Human Services Offce for Civil Rights by sending a letter to
200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/
hipaa/complaints/
• We will not retaliate against you for fling a complaint.
Your Choices
This section addresses your choices regarding health information
we may share.
You have the choice to tell us to:
• Share information with your family and friends about your
condition.
• Disclose your health information when disaster relief organizations seek your health information to coordinate your care. Note:
If you are unable to communicate your preference, for example if
you are unconscious, we may go ahead and share your information if we believe it is in your best interest.
We will never share your information in these
cases without permission:
• Marketing purposes. We are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may use and disclose
health information to tell you about health‐related benefts or services that may be of interest to you.
• Sale of your information. Under no circumstances will we sell
our patient lists or your health information to a third party without
your written authorization
Our Uses and Disclosures
This section lists ways in which we may use your information and
disclose it.
Healthcare Treatment
• Plan your care and treatment, including preauthorization and precertifcation.
• Communicate with other providers such as referring physicians.
• Billing and coordination of payment for services with health plan
administrator.
• Quality and outcome assessments for improvement of care
we render.
• Contracted third‐party business associates for services, such as answering services, transcriptionists, record keeping, consultants, and
legal counsel.
• Communicate to you via newsletters, mailings, or other means
regarding treatment options, health related information, disease
management programs, wellness programs, or other community
based initiatives or activities in which our practice is participating.
Public Health and Safety Issues
• Product recalls
• Reporting suspected abuse, neglect or domestic violence in compliance with state and federal laws.
Compliance with the law
• Department of Health and Human Services investigations for
complying with federal privacy laws.
• Address workers’ compensation, law enforcement, and other
government requests.
• Respond to lawsuits and legal actions such as a court order, subpoena, warrant, summons, or similar process if authorized under
state or federal law.
• If you become deceased, we may disclose health information to
an executor or administrator of your estate to the extent that person is acting as your personal representative.
Our Responsibilities
• If you have a personal representative, such as a legal guardian,
we will treat that person as if that person is you with respect to
disclosures of your health information.
• We are required to notify you by frst class mail or by email (if you
have indicated a preference to receive information by e‐mail), of
any breaches of Unsecured Protected Health Information as soon
as possible, but in any event, no later than 60 days following the
discovery of the breach.
• To provide you with notice, such as this Notice of Privacy Practices and abide by the terms of our most current Notice of Privacy
Practices;
• Notify you if we are unable to agree to a requested restriction.
Changes to the Terms of this Notice
We reserve the right to change our practices and to make the new
provisions effective for all your health information that we maintain.
Should our information practices change; a revised Notice of Privacy
Practices will be available upon request. We will not use or disclose
your health information without your authorization, except as described in our most current Notice of Privacy Practices. If you have
limited profciency in English, you may request a Notice of Privacy
Practices in [name of language(s)].
© 2017 KMC University / Kathy Mills Chang, Inc. All Rights Reserved.
a language requested.