|Joint Notice 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.
The Marion County Health Department (HD) works with other practitioners in delivering services to you. The
practitioners include doctors who are not part of the HD’s workforce. All of these practitioners will follow this Joint
Notice of Privacy Practices in delivering service to you. These practitioners include: Dr. Elizabeth Franczyk, Dr.
Matt Stedelin, Dr. Edward Stanford and Dr. A Rahman.
The HD and the practitioners involved in your care create a medical record of your health information in order to
treat you, receive payment for services delivered, and to comply with certain policies and laws. The uses and
disclosures described in this Notice are applicable to the health department and all of the practitioners
(collectively “we”) who are part of this Joint Notice of Privacy Practices while they are delivering services at a health
department facility or on behalf of the health department. This Joint Notice does not apply to service providers who
are not part of the health department when they deliver services elsewhere or only on their own behalf.
We are required by federal and state law to maintain the privacy of your PHI. We are also required by law to
provide you with this Notice of our legal duties and privacy practices. In addition, the law requires us to ask you to
sign an Acknowledgment that you received this Notice.
This is a list of some of the types of uses and disclosures of PHI that may occur:
Treatment: We obtain medical information about you in treating you. This medical information is called “protected
health information” or “PHI”. Your PHI is used by us to treat you. For example, we refer to PHI in treating you at the
health department. We may also send your PHI to another physician or counselor to which we refer you for
treatment. We may also use your PHI to contact you to tell you about alternative treatments, or other health-related
benefits we offer. If you have a friend or family member involved in your care, we may give them PHI about you.
Payment: We use your PHI to obtain payment for the services that we render. For example, we send PHI to
Medicaid, Medicare, or your insurance plan to obtain payment for our services.
Health Care Operations: We use your PHI for our operations. For example, we may use your PHI in determining
whether we are giving adequate treatment to our clients. From time-to-time, we may use your PHI to contact you to
remind you of an appointment.
Legal Requirements: We may use and disclose your PHI as required or authorized by law. For example, we may
use or disclose your PHI for the following reasons:
Public Health: We may use and disclose your health care information to prevent or control disease, injury or
disability, to report births and deaths, to report reactions to medicines or medical devices, to notify a person who
may have been exposed to a disease, or to report suspected cases of abuse, neglect or domestic violence.
Health Oversight Activities: We may use and disclose your PHI to state agencies and federal government
authorities when required to do so. We may use and disclose your health information in order to determine your
eligibility for public benefit programs and to coordinate delivery of those programs. For example, we must give PHI
to the Secretary of Health and Human Services in an investigation into our compliance with the federal privacy rule.
Judicial and Administrative proceedings: We may use and disclose your PHI in judicial and administrative
proceedings. Efforts may be made to contact you prior to a disclosure of your PHI by the party seeking the
Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant to a court order,
warrant, subpoena, summons, or similar process. We may use and disclose PHI to locate someone who is
missing, to identify a crime victim, to report a death, to report criminal activity at our offices, or in an emergency.
Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or someone else from
Work-Related Injuries: We may use or disclose PHI to an employer if the employer is conducting medical
workplace surveillance or to evaluate work-related injuries.
Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or medical
examiner in some situations. For example, PHI may be needed to identify a deceased person or determine a
cause of death. Funeral directors may need PHI to carry out their duties.
Armed Forces: We may use or disclose the PHI of Armed Forces personnel to the military for proper execution of a
military mission. We may also use and disclose PHI to the Department of Veterans Affairs to determine eligibility
National Security and Intelligence: We may use or disclose PHI to maintain the safety of the President or other
protected officials. We may use or disclose PHI for the conduct of national intelligence activities.
Correctional institutions and custodial situations: We may use or disclose PHI to correctional institutions or law
enforcement custodians for the safety of individuals at the correctional institution, those that are responsible for
transporting inmates, and others.
Research: You will need to sign an Authorization form before we use or disclosure PHI for research purposes
except in limited situations. For example, if you want to participate in research or a clinical study, an Authorization
form must be signed.
Fundraising: If we undertake any fundraising activities, we may contact you about the fundraising activity. We do
not engage in marketing activities, and need your authorization to do so.
Illinois law: Illinois law also has certain requirements that govern the use or disclosure of your PHI. In order for
us to release information about mental health treatment, genetic information, your AIDS/HIV status, and alcohol or
drug abuse treatment, you will be required to sign an authorization form unless state law allows us to make the
specific type of use or disclosure without your authorization.
Your Rights: You have certain rights under federal privacy laws relating to your PHI. Some of these rights are
Restrictions: You have a right to request restrictions on how your PHI is used for purposes of 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
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 of your
PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your
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.
Complaints: If you feel that your privacy rights have been violated, you may file a complaint with the health
department by calling our Privacy Officer at (618)548-3878. We will not retaliate against you for filing a complaint.
You may also file a complaint with the Secretary of Health and Human Services in Washington, DC if you feel your
privacy rights have been violated.
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 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 those persons to follow this Notice unless they are already required by law to
follow the federal privacy rule.
EFFECTIVE DATE: April 14, 2003