Suburban Radiologic Consultants, Ltd. Patient Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed by our office and also how you may access and control your health information.

• Treatment: We will use your information to provide, coordinate and manage care and treatment.  For example we will release films and reports to another medical provider who is involved in your care.
• Payment: We will use information to receive payment for services we provide. For example we will disclose information in order to submit bills or claims to insurance companies and/or Medicare or State funded plans. When a patient neglects to make timely payments on balance due, Suburban Radiologic Consultants, Ltd. (SRC) may use a collection agency.
• Health Care Operations: We will use information for certain activities related to business functions of SRC. For example, we may use or disclose information for quality assurance activities.
• Appointment Reminders and Treatment Alternatives: At our imaging centers we may contact you to remind you of an appointment or we may need to reschedule your appointment. Your health information may be used to inform you about health care services that may be of interest to you.
• Family Members or Individuals Involved in Your Care: You may agree to have verbal information about your treatment or diagnosis shared with a family member or designee. If you are unable to make health care decisions, SRC may disclose relevant medical information to family members or other responsible individuals involved in your care.  For example, you may give verbal consent for a radiologist to share with your designee information about your procedure.
• Other Uses or Disclosures: We may disclose or use information in the following situations: for public health activities; as it relates to victims of abuse/neglect/domestic violence; for health oversight activities;  for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes, as permitted or required by law; to coroners/medical examiners/funeral directors, as permitted by law; for organ donation purposes; for research purposes under certain circumstances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge, national security and intelligence; and for workers’ compensation purposes.

Your individual Privacy Right as a patient include the following:

• Inspection and Copy: You may make a request in writing to review or order a copy of your medical record, with the exception of information protected by law. However, we ask that you obtain your report from your ordering physician before we will make a copy available to you. In our practice your medical record is limited to films, reports and billing information of imaging procedures you received by us. We have the right to ask you for this request in writing and we will respond within a reasonable time frame. There may also be a reasonable charge for copies.
• Confidentiality: You have the right to make a request in writing that SRC provide you with your medical information in a confidential manner.  For example, if you request that we mail information to another address, we will agree to your request to the extent we are able to assure accuracy in doing so.
• Restrict Use and Disclosure: You have the right to make a request in writing that SRC not use medical information in certain ways or for certain purposes.  You may also request that we not provide medical information to certain individuals.  However, SRC has the right to refuse your request, particularly when the law requires it.
• Change Information or Amend Medical Records: You have the right to request in writing that we correct information in your medical record if we were the originator of such information.  If your request is denied, you may write a statement of disagreement with the denial that we will keep with your medical information.
• Accounting of Disclosures: You have the right to make a request in writing for an accounting of disclosures of health information that was made without your signature. Requests for accountings will not include disclosures made prior to April 14, 2003.  Your request can go back six years after April 14, 2009.
• Paper Copy of SRC’s Patient Notice of Privacy Practices: If you have received this notice of the medical information privacy rights electronically, you may ask us to provide you with a paper copy.
• Privacy Violations: If you feel your medical information privacy rights have been violated, you may file a complaint with SRC’s contact person listed below or with the Secretary of Health and Humans Services.  Filing a complaint will not affect the quality of the services you receive from SRC and you will not be retaliated against for filing a complaint. If you have a complaint or a question regarding your privacy rights, please contact:

Suburban Radiologic Consultants	U.S. Department of Health & Human Services
Coding & Compliance Manager	Office for Civil Rights, Region V
4801 W 81st Street, Suite 108 Bloomington, MN 55437	233 N Michigan Avenue, Suite 240 Chicago, IL  60601
(952) 837-9791	Phone: (312) 886-2359  Fax: (312) 886-1807
TDD: (312) 353-5693

The effective date of this notice is April 14, 2003.  SRC reserves the right to change this notice and will make the new information available to you by posting it in our offices and electronically on SRC’s web site at www.subrad.com.

Effective April 14, 2003