Click here to learn how you can get a copy of your medical records.

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.

This Notice, which became effective on August 2, 2004, applies to the following Advocate Health Care Sites:

Hospitals and Medical Staffs
Advocate Bethany Hospital
Advocate Christ Medical Center and Hope Children's Hospital
Advocate Good Samaritan Hospital
Advocate Good Shepherd Hospital
Advocate Illinois Masonic Medical Center
Advocate Lutheran General Hospital
Advocate South Suburban Hospital
Advocate Trinity Hospital

Medical Groups
Advocate Health Centers
Advocate Medical Group
Dreyer Clinic, Inc

Others
Advocate Home Care Products, Inc.
Advocate Home Health Services
Advocate Hospice
ACL (Lab Venture)
Family Care Network
High Technology, Inc.
Occupational Health Centers
Any other health care facility or physician practice currently owned by Advocate.

Disclaimer
This Advocate Health Care ("Advocate") site has decided to use a joint Notice of Privacy Practice and a joint Acknowledgement Form with independent physicians who are not employed by Advocate. The use of these joint forms rather than the use of separate notices and forms is being done only for the patient's convenience and to improve the access to patient health information by the patient's physician.

Although this notice does address the sites listed on the first page of the notice, any independent physicians are and remain independent contractors and are not agents, servants or employees of Advocate and are solely responsible for their judgment and (medical) conduct in treating or providing professional services to the patient and for their compliance with state and federal privacy laws. Nothing in this privacy notice is meant to imply, infer or create any agency or employment relationship between any independent physicians and Advocate, either actual or implied; (nor is it intended to create reliance on the part of the patient); nor is this privacy notice intended to alter or limit any other consents for treatment or procedures the patient may sign during the time the patient is provided care at this facility.

THIS NOTICE BECAME EFFECTIVE ON AUGUST 2, 2004.

UNDERSTANDING YOUR HEALTH INFORMATION AND MEDICAL RECORD
Each time you visit a hospital, physician, or other health care provider, they document information about you and your visit. Typically, this record is referred to as your medical record and contains your name, symptoms, health history and exam, test results, diagnoses, treatment given and a plan for future care or treatment ("Health Information"). This medical record is used to plan your care and treatment and be a source of your health information as described below.

YOUR HEALTH INFORMATION RIGHTS
Your medical record is the physical property of the Advocate Health Care site, however the information within your medical record belongs to you. Federal and Illinois laws provide you with the following rights regarding your health information that is contained in the medical record that Advocate Health Care keeps about you.
- Right to obtain a copy of this Notice of Privacy Practices.
- Right to request certain restrictions on the uses and disclosures of your health information.
- Right to inspect or receive a copy of your health record.
- Right to request an amendment to your health record if you believe it contains an error.
- Right to obtain a list of certain people and companies to which Advocate Health Care has released your health information (an "accounting" of disclosures).
- Right to request that we communicate with you about your health care at a confidential phone number or address.
- Right to revoke your written consent/authorization to use or disclose your health information except when the use or disclosure has already happened.
Federal and Illinois laws also provide you with the right to be informed about and give your written authorization before any health information, including highly confidential information, is disclosed, unless such disclosure is allowed or required by law. Examples of highly confidential information are mental health treatment, substance abuse or referral, developmental disability services, HIV/AIDS testing and treatment, venereal disease treatment, sexual assault treatment and testing, and for genetic disorders treatment.

ADVOCATE HEALTH CARE'S RESPONSIBILITIES
- Maintain the privacy of your health information as required by law.
- Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
- Do what is required by this Notice or a Notice that is in effect at the time Advocate Health Care uses or discloses your health information.
- Notify you if we are unable to agree to your requested restriction on disclosure of your health information.
- Agree to reasonable requests to communicate your health information by an alternative method or to an alternative location.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
Advocate Health Care will use and disclose your health information contained within the Advocate medical record to give you treatment, obtain payment for your treatment and operate our health care businesses.

EXAMPLES OF HOW YOUR HEALTH INFORMATION WILL BE USED OR DISCLOSED FOR TREATMENT, PAYMENT AND OPERATIONS

We will use your health information for treatment.
For example: Your physician, nurse and other members of your health care team will collect and document information about you in your medical record. We may disclose information to a physician or other health care provider who will be assuming your care, for immediate continuity of care. This health information will be used to choose the treatment they believe is best for you. Nurses and other members of the team will document in your medical record the actions they took and their observations of you. Your physician will then know how you are responding to the chosen treatment.

We will use your health information for payment.
For example: We will send a bill that includes some of your health information to you, to the person responsible for the bill and your third party payer (such as your health insurance company or Medicare). In some instances, we may need to send a copy of part or all of your medical record to your third party payer. The type of health information we will send includes your name, other identifying information, diagnosis, treatment, procedures performed and supplies provided during your treatment.

We will use your health information for our routine operations.
For example: Physicians, nurses and quality improvement professionals will use your health information to review the treatment you received and its outcomes. They also may compare your treatment and outcomes to those of other patients like you. We compare cases to help us learn how to improve the quality and effectiveness of our health care services.

OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION

Upon receipt of your written authorization to use and/or disclose your health information.
We will use and/or disclose your health information to those persons or companies for which you give us your written authorization or permission to do so. If you authorize us to use or disclose your information, you must complete our Release of Health Information Form. You may revoke your authorization in writing at any time except to the extent that we have already used or disclosed your health information as you previously authorized. If your health information includes highly confidential information, we may only use and disclose such information for treatment, payment and operations as described above. Otherwise, unless a disclosure is allowed or required by federal or Illinois law, you must give us your written authorization to disclose your highly confidential information. A person who can verify your identity must witness and co-sign an Authorization to Release Health Information form about treatment for mental illness or developmental disability.

Advocate may without your written authorization release your health information for the purposes described below.
Notification and Other Communications with Your Relatives, Close Friends or Caregivers. You or your legal representative must tell your physician, nurse or other health care team members which of your relatives or other persons may receive information about you. After learning who these persons are, we may, in our best judgment, use and disclose your health information, except for your highly confidential information, to notify these person(s) of what they need to know to care for you. In an emergency or other situation where you are not able to identify your chosen person(s) to receive communications about you, we may exercise our professional judgment to determine whether such a disclosure is in your best interest, who is the appropriate person(s) and what health information is relevant to their involvement with your health care.

Other Communications with You. We may contact you to remind you of appointments with your physicians or other health care team members and to follow up on the services you received. We may leave messages about appointments or other reminders on your telephone or with a person who answers the phone.

Business Associates. We provide some services through other persons or companies that need access to your health information to carry out these services. The law refers to these persons or companies as our Business Associates. We may disclose, as allowed by law, your health information to our Business Associates so that they can do the job we have contracted with them to do. Examples of Business Associates include companies that assist with billing services or copying medical records. We may send other business associates called registries (such as a Cancer Registry) summarized information about patients who have been treated with similar problems such as cancer or trauma, to help physicians throughout Illinois improve the quality of care for other patients with similar problems. We require that our business associates use appropriate safeguards to ensure the privacy of your health information.

Health Oversight Activities and Specialized Government Functions. We may disclose your health information to an agency that oversees health care systems and ensures compliance with the rules of government health programs such as Medicare or Medicaid and under certain circumstances to the U.S. Military or U.S. Department of State.

Law Enforcement Officials, Medical Examiners and Coroners and Court or Administrative Orders. We may disclose your health information to the police, other law enforcement officials, medical examiners and coroners, and to the courts or administrative proceedings as allowed or required by law, or required by a court order or other legal process.

Funeral Directors and Organ, Eye and Tissue Organizations. We may disclose your health information to funeral directors as necessary to carry out their duties and as allowed by law; or to organ, eye and tissue organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Public Health Activities. We may report your identity and other health information to: public health authorities for the purpose of controlling disease, injury or disability; to the U.S. Food and Drug Administration for regulating certain products or activities; to governmental authorities about suspected or known child abuse and neglect, elder adult abuse and neglect, or domestic violence; to a person exposed to a contagious disease or has the risk of contracting or spreading a disease; to your employer and governmental agencies as required by federal and state laws regarding work-related illness or injury; to prevent or lessen a serious or imminent threat to a person's or the public's health or safety; or, to a public or private entity that is authorized to assist in disaster relief efforts.

Research. We may use or disclose your health information to identify you as a potential candidate for a research study that has been approved by an Institutional Review Board or for governmental research studies in which your identifiable information will not be released.

Workers Compensation. We may disclose your health information as allowed or required by Illinois law relating to workers' compensation or to other similar programs.

Fundraising. In the continuing effort to enhance Advocate Health Care's capacity to conduct its mission of service to patients and families, periodic communications and invitations to donate may be sent to patient families and friends of Advocate Health Care by the Advocate Charitable Foundation. The law allows us to share minimal information about you with our fund-raising foundation. However, we will not provide information about you to the Advocate Charitable Foundation if you notify or call the Foundation at the number listed below. Advocate will not share your information with other organizations.

If you object to using your health information for fundraising, please contact: Advocate Charitable Foundation
at (847) 384-3400.

Marketing. Advocate Health Care will not use or disclose your health information without your written authorization for marketing purposes.

Other Uses of Your Information. Advocate Health Care may provide you with face-to-face or other communication about products or services related to your treatment, case management, or care coordination, or alternative treatments, therapies, health care providers, or care settings.

USES AND DISCLOSURES THAT YOU MAY OBJECT TO OR REQUEST

Directory (Hospitals Only): When you are a patient in our hospital, we may list your name, location in our hospital, and religious affiliation in our inpatient directory. We may disclose your name, location in our hospital and religious affiliation to a member of the clergy who presents the appropriate identification and asks for you by your name or by your listed religious affiliation. We may disclose your name and general condition to a member of the media who asks for you by name. We may disclose your name and location in the hospital to a member of the general public who asks for you by name. If you do not want to be listed in our hospital directory or do not want us to give such information to members of either the clergy, media, or general public, you must inform your nurse or your registration coordinator. Please note that if you are not listed in our hospital directory, we will tell all individuals who ask for you at the visitors' desks or who call the operator that you are not currently a patient.

If you are receiving mental health or alcohol/substance abuse services on an inpatient behavioral health unit during this hospitalization, we will not disclose any information without your prior written authorization.

If you object to using your health information for the hospital directory, please contact: Not applicable for Medical Groups

RIGHT TO FILE A COMPLAINT
If you would like to report a Privacy Problem or want further information, please contact: Dreyer Privacy Line at (630) 906-5053

If you believe your privacy rights have been violated, you may file a complaint with Advocate Health Care, the Director of the Office of Civil Rights (OCR) or the U.S. Secretary of Health and Human Services (HHS). We will not retaliate against you if you file a complaint with us or with the Directors of OCR or HHS.

DISCLAIMER:
We reserve the right to change our privacy practices and to use a new Notice of Privacy Practices. If Advocate Health Care changes its practices, a new Notice of Privacy Practices will be available upon your request, by mail or in person at this site. This Notice of Privacy Practices has been adopted as the only approved Notice for use throughout Advocate Health Care. Any changes are unauthorized and invalid.

Copies of Medical Records

All requests for copies of medical records should be directed to the Release of Information area in the Medical Records Department on the lower level of Dreyer Medical Clinic's West Aurora site at 1870 West Galena Boulevard, Aurora, Illinois, 60506, between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday. You may also call 630-859-7266 for assistance. All requests are processed within three to five days after the appropriate completed release forms have been received.

Fees have been established for the copying of medical records in accordance with legislation enacted by the State of Illinois in September of 2001. Fees will vary depending on the volume of the records requested. Contact the Medical Records Department at 630-859-7266 to determine the exact costs for the records you need.

Downloadable Authorization Release Form

 Click Here to download an English version of the authorization form.

 Click Here to download a Spanish version of the authorization form.

(Adobe Acrobat Reader required.)