Search (708) 342-8100 Our Story Services Living Options Communities Contact Events News Resources Careers Giving Notice of Privacy Practices Information on Privacy of Your Health Information 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. Providence Life Services (“Providence”) is required by law to maintain the privacy of your protected health information (“PHI”) and to provide you with a notice of its legal duties and privacy practices. State and federal laws require Providence to: maintain the privacy of your health information; provide you with this Notice of Privacy Practices (“Notice”) about its legal duties and privacy practices and your legal rights pertaining to health information it collects and maintains about you; to notify you following a breach of unsecured protected health information; follow the privacy practices described in this Notice while it is in effect; notify you if it is unable to agree to a requested restriction pertaining to your health information; and accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. Providence will abide by the terms of the Notice currently in effect. Providence reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI it maintains. If we change this Notice, the revised Notice will be posted in our facilities, offices, and on our website (www.providencelifeservices.com), or a copy of the revised Notice will be mailed to the resident or patient. This Notice applies to all of the medical records generated or received by Providence. TREATMENT In order to adequately treat our residents and patients, we provide complete information to healthcare providers, including members of our workforce and business associates. For example, a nurse caring for you will report any changes in your condition to a physician, a therapist, other nurses, and/or nurse’s aides so that you can receive the treatment you need. PAYMENT Health information is exchanged daily with various payers: Medicare, Medicaid, private insurances, third party payers, or other entities (or their authorized representatives) involved in the payment of your medical bill. This information is used to verify benefits, submit for payment, and project and arrange for future care. For example, a bill sent to an insurance company may include information that identifies you, your diagnosis, and any procedures or supplies used. HEALTHCARE OPERATIONS The organization may use or disclose your health information as a part of healthcare operations. Examples of daily operations in which such information may be used include: quality assurance, internal auditing, certification, licensure, and educational purposes. DISASTER RELIEF We may disclose your personal health information to an organization assisting in a disaster relief effort. NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES Providence may disclose health information to authorized federal officials conducting national security and intelligence. PUBLIC HEALTH As required by law, Providence may disclose your health information to public health or other governmental authorities charged with preventing or controlling disease, injury, or disability. WORKERS COMPENSATION We may release health information about you to Workers Compensation, which provides benefits for work-related injuries or illnesses. FUNERAL DIRECTORS, CORONERS, MEDICAL EXAMINERS, ORGAN PROCUREMENT ORGANIZATIONS Providence may release your health information to a funeral director if needed to carry out funeral-related duties, to organizations that handle organ procurement or transplantation, or to an organ donation bank to support the process. REPORTING VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE If we believe that you have been a victim of abuse, neglect, or domestic violence, we may disclose your personal health information to notify a government authority if required or authorized by law. TO INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE During times of treatment, we disclose your PHI only to you, a family member, personal representative, or another person responsible for your care. We may use or disclose your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, regarding your location and general condition. TO PROVIDE YOU NOTICE OF BREACHES OF UNSECURED PHI We may contact you to provide you with any notice of any breach of your unsecured PHI. OTHER USES Uses and disclosures of an individual’s health information for purposes other than those listed will be made only with the resident’s or patient’s written authorization, which later may be revoked. For example, a specific authorization will be required for use or disclosure of your PHI 1) if it involves certain psychotherapy notes, 2) for marketing (except if the communication is face-to-face, or is for a promotional gift of nominal value) or for any marketing that involves financial remuneration; or 3) for any sale of your PHI. In these situations, you may withdraw your authorization at any time and must do so in writing to Providence. Your withdrawal may not be effective in certain situations where we have already taken action in reliance on your authorization. INDIVIDUAL RIGHTS The resident or patient has the following rights related to his or her health information: The right to request restrictions on our use or disclosure of your personal health information. We are not required to agree to your request. If we do agree, we will comply with your request unless (1) you are being transferred to another health care institution, (2) the release of records is required by law, or (3) the release of information is needed to provide you emergency treatment. The request must be in writing and sent to Providence (to the Privacy Officer, contact information provided at the end of this Notice). If you request, we must agree to restrict disclosures to health plans if you pay out of pocket in full for any service we provide. The right to receive confidential communication of PHI by alternate means or at an alternate location (for example, your home). The right to inspect and have copied your PHI. Charges may apply. The right to amend PHI: Your request must be in writing. There are limitations to amendatory rights. The right to receive an accounting of disclosures of protected health information: Your request must be in writing. Charges may apply. The right to receive a copy of this notice upon request or access it at www.providencelifeservices.com. The right to revoke your authorization to use or disclose your PHI, except where we have already taken action in reliance on your authorization. REPORTING OF CONCERNS OR NEED FOR MORE INFORMATION If you have questions, would like additional information, or if you believe we have violated your privacy rights, you may call or write to the Administrator or the Privacy Officer at Providence Life Services (708-342-8137), 18601 North Creek Drive, Tinley Park, Illinois 60477. You also may send a complaint to the U.S. Department of Health and Human Services (“DHHS”). Further information may be found at: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. All complaints must be submitted in writing. We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with DHHS. DM2\4381389.2 Find Us 18601 North Creek Drive Tinley Park, IL 60477 info@provlife.com (708) 342-8100 Providence Life Services is a 501(c)3 not-for-profit organization. Follow Us Facebook Linkedin Blog YouTube Contact Us Email Address Message In compliance with the Fair Housing Act, we do not discriminate because of race or color, national origin, religion, sex or gender, familial status, or disability. Notice of Privacy Practices