Notice of Patient Privacy

Updated February, 2016

Your information is important and confidential. Our ethics and policies require that your information be held in strict confidence.

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.


We maintain protocols to ensure the security and confidentiality of your personal information. We have physical security in our building; alarm system, individual passwords change every 90 days to protect databases, e-mail encryption, compliance audits, and virus/intrusion detection software backed up daily. Within our practice, access to your information is limited to those who need it to perform their jobs.

At the offices of Advanced Dermatology & Mohs Surgery, we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Policies describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective February 2016, and applies to all protected health information as defined by federal regulations.

Understanding Your Health Record

Each time you visit Advanced Dermatology & Mohs Surgery, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, 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 third-party payer can verify that services billed were actually provided
  • Tool in educating health professionals
  • Source of data for medical research
  • Source of information for public health officials charged to improve the health of the state and nation
  • Source of data for our planning and marketing
  • Tool by which we can assess and continually work to improve the care we render and outcomes we achieve

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy; better understand who, what, when, where, and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of Advanced Dermatology & Mohs Surgery, the information belongs to you. You have the right to:

  • Obtain a paper copy of this notice of privacy policies upon request
  • The right to prohibit the sale of their PHI, its use for marketing purposes, or participation in research.
  • Right to get notice of a Breach.
  • Choose someone to act for you
  • Inspect and obtain a copy of your PHI, paper or electronic, as provided by 45 CFR 164.524 (reasonable copy fees apply in accordance with state law)
  • Amend your PHI as provided by 45 CFR 164.526
  • Obtain an accounting of disclosures of your PHI as provided by 45 CFR 164.528
  • Request confidential communications of your protected health information as provided by 45 CFR 164.522(b)
  • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522(a) (however, we are not required by law to agree to a requested restriction).

Our Responsibilities

Our practice is required to:

  • Maintain the privacy of your health information
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction
  • Accommodate reasonable requests you may have to communicate your health information.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notice in our facility containing the effective date in the top, right-hand corner. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon request.

We will not use or disclose your health information in a manner other than described in the section regarding Examples Of Disclosures For Treatment, Payment, And Health Operations, without your written authorization, which you may revoke as provided by 45 CFR 164.508(b)(5), except to the extent that action has already been taken.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact our practice’s Privacy Officer, M. Horton, at (630) 482-3700 or by other means. If you believe your privacy rights have been violated, you can either file a complaint with the office manager, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our practice of the OCR. The address for the OCR regional office for Illinois is as follows:

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240 Chicago, IL 60601
For complaints; Call: OIG(DHHS): 800-377-4950
Or visit/call OCR at: [email protected] /TDD: 800-537-7697

Examples of Disclosure for Treatment, Payment, and Health Operations

We will use your health information for treatment

We may provide medical information about you to health care providers, our practice personnel, or third parties who are involved in the provision, management, or coordination of your care.
For example:
Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your medical information will be shared among health care professionals involved in your care.
We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) with copies of various reports, including photographs, that should assist them in treating you.

We will use your health information for your payment

We may disclose your information so that we can collect or make payment for the health care services you receive.
For example:
If you participate in a health insurance plan, we will disclose necessary information to that plan to obtain payment for your care.
Under the HITECH HIPPA rules updated and effective March, 2013, it is stated that a patient has the right to refuse to use their medical coverage benefits.  In doing so, he/she will be required to sign a “Confidentiality Proviso “ form to that effect.  The patient will also be responsible for paying for services rendered at the time of the visit or procedure.  All follow-up visits connected to the initial visit must also be paid by the patient.

We Will Use Your Health Information for Regular Health Operations

We may disclose your health information for our routine operations. These uses are necessary for certain administrative, financial, legal, and quality improvement activities that are necessary to run our practice and support the core functions.
For example:
Members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide and to reduce healthcare costs.

Appointment Reminders

We may disclose medical information to provide appointment reminders (e.g., contacting you at the phone number you have provided to us and leaving a message as an appointment reminder).


Consistent with applicable law, we may disclose health information to a coroner, medical examiner, or funeral director.

Workers Compensation

We may disclose health information to the extent authorized by and necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health

As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.


We may disclose information to researchers when their research has been approved and the researcher has obtained a required waiver from the Institutional Review Board/Privacy Board, who has reviewed the research proposal.  Thus, includes the encompass of future research.

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 donation and transplant.   Living will does not apply to practice.

As Required By Law

We may disclose health information as required by law. This may include reporting a crime, responding to a court order, grand jury subpoena, warrant, discovery request, or other legal process, or complying with health oversight activities, such as audits, investigations, and inspections, necessary to ensure compliance with government regulations and civil right laws.

Specialized Government Functions

We may disclose health information for military and veteran’s affairs or national security and intelligence activities.

Business Associates

There are some services provided in our organization through contacts with business associates. Some examples are billing or transcription services we may use. Due to the nature of business associates’ services, they must receive your health information in order to perform the jobs we’ve asked them to do. To protect your health information, however, when these services are contracted we require the business associate to appropriately safeguard your information.

Practice Marketing

We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you (e.g., to notify you of any new tests or services we may be offering).

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.

Personal Representative

We may disclose information to your personal representative (person legally responsible for your care and authorized to act on your behalf in making decisions related to your health care)

To Avert A Serious Threat To Health/Safety

We may disclose your information when we believe in good faith that this is necessary to prevent a serious threat to your safety or that of another person. This may include cases of abuse, neglect, or domestic violence.

Communication With Family

Unless you object , health professionals, using their best judgment, may disclose to a family member or close personal friend health information relevant to that person’s involvement in your care or payment related to your care. We may notify these individuals of your location and general condition.

Disaster Relief

Unless you object , we may disclose health information about you to an organization assisting in a disaster relief effort
For all non-routine operations, we will obtain your written authorization before disclosing your personal information. In addition, we take great care to safeguard your information in every way that we can to minimize any incidental disclosures.

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Office Hours


8:30 am-5:00 pm


8:30 am-5:00 pm


8:30 am-5:00 pm


8:30 am-5:00 pm


9:00 am-3:00 pm