- 309 S. Galena Ave., Ste. 100, Dixon, IL 61021
- Monday-Friday 8:00AM-4:30PM
- Phone: 815-284-3371
- After-Hours Emergency: 815-284-6631
- Fax: 815-288-1811
- Email: firstname.lastname@example.org
- Facebook: @LCHDIL
EFFECTIVE DATE: December 1, 2016
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.
Lee County Health Department (LCHD) creates 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. This 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 Protected Health Information “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, but not limited to: Mandated reporting, Court Subpoena.
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 information.
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 getting hurt.
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.
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 described below:
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. You have the right to choose/request phone call reminders about your appointments or text message reminders. You can revoke or change this at any time.
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 our 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 options.
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 Disclosures: You have a right to receive an account of disclosures that we have made of you PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization.
Copy of Notice: You have a right to obtain a paper copy of this Notice, even if you originally received the notice electronically.
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 (815) 284-3371. 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 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 on our website at www.lchd.com , or 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 healthcare operations activities, we will require those persons to follow this Notice unless they are already required by law to follow the federal privacy rule.
If you would like any further information concerning this form or the Health Department’s privacy practices, please contact Director of Maternal and Child Health Services, at (815) 284-3371.
I agree to have myself/child/children participate in the Maternal & Child Health (MCH) Programs. I understand that enrollment in the MCH Program will help promote good health and community service referrals.
The MCH programs have been explained and I am willing to abide by the regulations required. I agree to keep all scheduled appointments and to notify the MCH program staff if I need to cancel an appointment and I agree to reschedule an appointment as soon as possible.
I understand that in order to provide comprehensive medical care, it is necessary for parties involved with the care of myself/child/children to share information. I give my consent for the Lee County Health Department to obtain and/or release information when it is deemed necessary for the continuity of care to agencies listed below, and collaborating individuals (e.g. private physician or insurance provider) including but not limited to those listed below.
Lee County Health Department /Illinois Department of Public Health/Collaborating Health Departments, Illinois Department of Human Services/Local Department of Human Services, Office of Rehabilitation Services, Social Security Administration, Medical Care Providers/Physicians, Medical Facilities/Clinics/Hospitals, Tri-County Opportunities Council, School Districts, Lee County Special Education, LSSI (Lutheran Social Services of Illinois), Northwestern Illinois Association Hearing Clinic, Department of Children and Family Services, Alcohol/Drug Treatment Center, DSCC (Department of Specialized Care for Children), YWCA, Catholic Social Services, Child & Family Connections/Early Intervention Programs, Mental Health Providers, Housing, 4C’s, Sinnissippi Centers Inc./Healthy Families Illinois, All Kids, Probation/Parole Officer, Lee County Jail, Illinois Department of Corrections (IDOC), Lee County Circuit Clerk (Motor Voter Registration), Local Law Enforcement Agencies, Lee Ogle Transportation (LOTs), First Transit.