Notice of Privacy Practices

Effective Date: April 14, 2003

Summary of Notice

This summary 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 following facilities of Centegra Health System, including Centegra Management Services, Inc.; Centegra Primary Care, LLC; Centegra Hospital-McHenry and Centegra Hospital-Woodstock, keep medical information about you. This information is personal and private. We need to use this information in many ways. First, we use the information when we treat you or communicate with those who are or will be involved in your care. Secondly, we use information about you to process payment for the medical care you received. Thirdly, we use this information for our health care operations, activities we engage in order to provide services to you and other patients. Under the law, each patient has certain rights to the medical information kept at the facilities of Centegra Health System. Certain restrictions may apply. These rights are:

• Access. You can ask to look at your information. You may receive a copy of your information.
• Restriction. You can ask to limit who sees your information. You can ask to limit what information is released.
• Alternative Communications. You can ask that we communicate with you by using a specified phone number or mailing address.
• Accounting. You can ask to see the list of places where your information has been released.
• Amending. You can ask to change medical information if you feel it is incorrect.

A complete notice with explanations of uses, disclosures, and rights as well as information on how to file a privacy complaint is available at the following:

• Attached to this Summary of Notice
• At any one of our patient registration sites
• For further information about the Notice of Privacy Practices or the privacy compliance program of Centegra Health System, please contact us as indicated on the last page of this Notice.

Notice of Privacy Practices

Our Pledge Regarding Health Information

Centegra Health System understands that information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facilities. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the facilities, whether made by facility personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This notice will tell you the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. The terms 'medical' and 'health' information and records have the same meaning.

Our Responsibilities

Centegra Health System is required to:

• Make sure that health information that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to your medical information.
• Follow the terms of the notice that is currently in effect.
• Notify you if we are unable to agree to a requested restriction.
• Inform you of applicable cost-based charges associated with your information requests.
• Accommodate reasonable requests you may have to communicate health information by alternative means or to an alternative location.
• Protect the privacy about a deceased individual as long as the information is maintained.

We reserve the right to change our practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the revised notice in our facilities and to our web site. We will also provide a copy of it to you during registration at your next visit.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• Request and have a paper copy of this notice.
• Inspect your health information as well as information to be disclosed.
• Receive a copy of your health information*, including medical and billing records. Fees may apply.
• Request corrections or additions to your health information*. Your request must state the reason for the requested amendment.
• Request a report of certain disclosures of your health information made by us*. The report does not include disclosures made for treatment, payment, health care operations, some disclosures required by law, or disclosures made via a signed authorization. Your request must state the period of time desired for the report, which must be within the 6 years prior to your request and exclude dates prior to April 14, 2003. The first report of disclosures is free but a fee will apply if more than one request is made in a 12-month period.
• Request restrictions on how we can use and share your health information*. We will consider all requests for restrictions carefully but are not required to agree to all restrictions.
• Request that we use a specific telephone number or address to communicate with you*.

Requests marked with an asterisk (*) must be made in writing. Contact the  Centegra Health System Privacy Office for the appropriate form for your request.

Understanding Your Health Record/Information

Each time you visit a Centegra Health System facility, physician, or other healthcare provider, a record of your visit is made. Your health record includes but is not limited to your diagnosis, treatment, insurance and demographic information and is privileged and protected by Federal and State law. This information, referred to as your health or medical record which may contain paper and electronic documents, photographs, videotapes, and other images, serves as a:

• Basis for planning your care and treatment.
• Means of communication among the many health professionals who contribute to your care.
• Legal document describing the care you received.
• Means by which you or a payer can verify that services billed were actually provided.
• Tool in educating health professionals.
• Source of information for public health officials charged with improving the health of the nation.
• Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
• Understanding what is in your health record allows you to ensure its accuracy. Understanding how your health information is used helps you to better understand who, what, when, where, and why others may access it and make more informed decisions when authorizing disclosures to others.

Confidentiality of Mental Health/Developmental Disabilities, and Alcohol or Drug Abuse Information

The confidentiality of mental health/developmental disabilities and alcohol or drug abuse patient records maintained by this program is protected by Federal and State laws. Generally, Centegra Health System may not acknowledge to anyone outside the program that a patient attends the program, or disclose any information identifying a patient participating in any of these programs unless one of the following conditions is met:

• The disclosure is for the purpose of payment for services received at our facilities.
• The patient gives written authorization for the disclosure.
• The disclosure is required by a court order.
• The disclosure is made to medical personnel in a medical emergency.
• The disclosure is made during a review by a federal or state agency.
• The disclosure is made for audit or accreditation purposes.
• Violation of the Federal or State laws is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal and State laws.

Uses and Disclosures

The following categories describe and provide some examples of different ways that we will use and disclose health information.

• Treatment. We will provide health information about you to physicians, nurses, technicians, students, and other healthcare team members who need the information to provide you treatment or services. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The physician may need to tell the dietitian if you have diabetes so that we arrange for appropriate meals. Different departments of the hospital also may share your health information to coordinate things you need such as prescriptions, lab work, and x-rays. We will also disclose health information about you to your physicians or other persons with copies of various reports that will assist in continuing your treatment outside our facility. For example, we may share your health information with other hospitals, physicians, nursing homes, or other health care providers as necessary to continue your care. We may contact you to provide appointment reminders or treatment alternatives.
• Payment. Unless you specifically restrict use or disclosures related to payment and we agree to your restriction, we will use your health information to bill for and obtain payment for treatment services you receive at our facility. For example, a bill/claim may be sent to you, an insurance company, third party payor, authorized agent, claims review organization, or collection agency. We may need to give information about surgery, medical treatment and continuum of care needs you received or will receive so that the health plan will pay us or reimburse you for the services. For pre-certification purposes, we may also tell your health plan about a treatment you are going to receive to obtain prior approval or determine whether your plan will cover the treatment. We may disclose your health information to other health care providers, such as an ambulance service, for the payment purposes of those providers.
• Health Care Operations. We may use and disclose health information about you for facility operations. This information is used in an effort to continuously improve the quality and effectiveness of the health care services we provide. For example, members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. We may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to physicians, nurses, and students for educational purposes. We may disclose limited health information about you to other health care providers for certain purposes of their operations.
• As Required or Permitted by Law. Sometimes we must report some of your health information to legal authorities, such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
• Contracted Services. There are some services provided in our organization through contracts with other service providers. Examples include physician services in the emergency department and radiology, collection agencies, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our service provider so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, all contracted service providers are required to appropriately safeguard your information.
• Correctional Institutions. Should you be an inmate of a correctional institution, we may disclose to the institution or its agents health information necessary for your health and the health and safety of other individuals.
• Directory. Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other individuals who ask for you by name as well as government agencies and disaster relief organizations in the event of a disaster.
• Family. Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information about you if that person is involved in your care or payment related to your care.
• Food and Drug Administration (FDA). We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
• Fundraising. We may contact you as part of a fundraising effort in support of Centegra Health System.
• Health Oversight Activities. We may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs.
• Law Enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
• Limited Data Sets. We may use or disclose a limited data set (i.e., in which certain identifying information has been removed) of your health information for purposes of research, public health, or health care operations. Any recipient of that limited data set must agree to appropriately safeguard your information.
• Marketing. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may communicate to you via newsletters, mail outs or other means regarding treatment options, disease management programs, wellness programs, or other community based initiatives or activities our facility is participating in.
• Medical Examiners, Coroners, and Funeral Directors. We may disclose health information to medical examiners, coroners, and funeral directors consistent with applicable law to carry out their duties.
• Minors. We will follow State Law as it relates to personal representatives or non-emancipated minors.
• Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
• Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• Patient. During the course of your treatment and services at our facility, there may be encounters in which a physician, nurse, or other health team member may need to discuss with you your health condition and plan of treatment in an area where the presence of others is unavoidable. We will make every reasonable effort to maintain the confidentiality of your health information during these situations.
• Public Health. As required by law, we may disclose your health information to certain government agencies and others charged with preventing or controlling disease, injury, or disability. Some examples include reporting communicable diseases, work-related illnesses or other diseases and injuries as permitted by law; reporting of births and deaths, and reporting reactions to drugs and problems with medical devices.
• Research. We may disclose health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
• Specialized Government Functions. Under certain conditions, we may disclose your health information if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, we may disclose, in certain circumstances, your information to the foreign military authority. We also may disclose your health information to authorized federal officials for conducting national security and intelligence activities, and for the protection of the President, other authorized persons or heads of state.
• To Avoid a Serious Threat to Health or Safety. As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to your or the public's health or safety.
• Worker's Compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Disclosures Requiring Specific Authorization

In addition to the special protections that apply to mental health, alcohol and drug abuse information, there are special privacy protections that apply to AIDS/HIV-related information, genetic information, and certain circumstances in which state law requires Centegra Health System to obtain a separate written authorization from you prior to our use or disclosure of your health information. Therefore, in certain circumstances your health information may not be released unless either we have your express written authorization or we are required by Federal or State Law to release the information. After you sign a written authorization, you may revoke your authorization, except to the extent that action has already been taken, by submitting a written request. More specific information may be obtained from Centegra Health System's Privacy Office.

Other Uses and Disclosures

Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you give us authorization to use and disclose your information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization.

Organized Health Care Arrangement

Centegra Health System and certain identified groups of independent contractor physicians at our facilities, as set forth in this joint Notice of Privacy Practices, use a joint notice and acknowledgment form to comply with Federal and State privacy rights and protections for patients whose rights are described in this joint notice. Centegra Health System uses a joint notice and acknowledgment form, rather than the use of separate notices and forms from the facilities and doctors solely for convenience to patients and to improve access to the separate health care services that the facilities and the doctors independently provide. The physicians in this arrangement include anesthesiologists, radiologists, pathologists, radiation oncologists, emergency room physicians, and occupational health physicians. These physicians are independent contractors and are not employees or agents of Centegra Health System, unless otherwise identified; and nothing in this notice is meant to imply, infer, or create any agency or employment relationship between the physicians and the facility, either actual or implied, nor does this notice alter, limit, or modify any consents for treatment or procedures in effect during the time care is provided at the facility. The physicians exercise their own medical judgment in providing treatment and professional services. They are solely responsible for their own compliance with Federal and State privacy laws. Information between the facilities and physicians will be shared as necessary to carry out treatment, payment, and health care operations. Physicians and other health care professionals may have access to your health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

Affiliated Covered Entity

Your health information will be made available to personnel at Centegra Health System hospitals and facilities as necessary to carry out treatment, payment, and health care operations. Centegra Health System has affiliated certain entities for the sole purpose of a common privacy program for compliance with the Health Insurance Portability and Accountability Act (HIPAA). These entities include: Centegra Management Services, Inc.; Centegra Primary Care, LLC; Centegra Hospital-McHenry and Centegra Hospital-Woodstock. Health care professionals at other facilities may have access to health information at their locations to assist in reviewing past treatment information as it may affect treatment at this time.

Important Notice

We reserve the right to revise this Notice. Each time you register for health care services at a site covered by this Notice, the most current copy of this Notice will be available for you.

Complaints

If you believe your privacy rights have been violated, we encourage you to file a complaint with Centegra Health System by contacting our Privacy Office at  (815) 759.4567. We will investigate all complaints and the treatment/services you receive from us will not be negatively affected by a filed complaint on your behalf. If you wish to file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services, you may submit a written complaint to the regional address: U.S. Department of Health and Human Services 233 N. Michigan Avenue, Suite 240 Chicago, IL 60601.

Contact Information

If you have any questions or complaints about your privacy or this notice, please contact: Centegra Health System Privacy Office/Quality Resources 4201 Medical Center Drive McHenry, IL 60050 (815) 759.4567 For general inquiries not related to your privacy, please use the phone numbers listed below:

Centegra Hospital - Woodstock

• Main hospital number  (general hospital information) (815) 338.2500
• Medical Records  (medical record copies) (815) 334.3111
• Patient Business Services  (billing inquiries) (815) 338.2544

Centegra Hospital - McHenry

• Main hospital number  (general hospital information) (815) 344.5000
• Medical Records  (medical record copies) (815) 759.4079
• Patient Business Services  (billing inquiries) (815) 338.2544