Notice of Privacy Practices

Joliet, IL
815/730-1100
744 Essington Road

Mokena, IL
708/478-1888
9475 Bormet Drive (192nd)
(1 block E. of Rt. 45 / LaGrange Rd.)

Bourbonnais, IL
815/802-1988
300 Riverside Dr., Suite 2200

Melrose Park, IL
708/681-7390
675 W. North Ave., Suite #212

Infertility Treatment
Patient Education Resource

User ID: 730110001

Password: rhs815

Providing the highest
quality infertility treatment in a warm & friendly environment.

Dr. Marek Piekos
Dr. Anthony J. Caruso
Board Certified OB/GYN - Reproductive Endocrinologist

Fully Accredited by the College of American Pathologists (CAP) & the Clinical Laboratory Inspection Agency (CLIA)

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 AND SAVE OR PRINT IT FOR FUTURE REFERENCE.

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations:

	Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.
	Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. An example of this would be billing your dental plan for your dental services.
	Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment alternatives or other health-related services. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have certain rights in regards to your protected health information, which you can exercise by presenting a written request to our Privacy Officer.

	The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
	The right to request to receive confidential communications of protected health information from us by alternative means or at alternative locations.
	The right to access, inspect and copy your protected health information.
	The right to request an amendment to your protected health information.
	The right to receive an accounting of disclosures of protected health information outside of treatment, payment and health care operations.
	The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terns of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

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