Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED,
AS WELL AS HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. EFFECTIVE 05/09/12.
If you have any questions, please contact our Privacy Office at the address or phone number at the end of this Notice.
Who will follow this Notice?
The Notice serves as a joint Notice for Memorial Health System’s (MHS) covered providers (collectively referred to herein as "we" or "our"). Because we are affiliated covered entities (ACE), as defined by the Health Insurance Portability and Accountability Act of 1996, we will follow the terms of this Notice and may share health information with each other for purposes of treatment, payment, and health-care operations as described in this Notice. The information
privacy practices in this Notice will be followed by all MHS covered entities which are legally separate, independent organizations and not partners or agents of each other and:
- All health care professionals who treat you at any of our locations.
- All of our employees, volunteers and Medical Staff members.
- All business associates with whom we share health information.
Where this Notice Applies
This Notice applies in the following locations:
- Passavant Area Hospital: Springfield
- Abraham Lincoln Memorial Hospital: Lincoln
- Taylorville Memorial Hospital: Taylorville
- Memorial Home Services:
- Home Health: Springfield, Taylorville, and Jacksonville
- Durable Medical Equipment: Springfield, Lincoln, Taylorville and Jacksonville
- Hospice: Springfield and Taylorville
- Private Duty Nursing: Springfield and Jacksonville
- Memorial Physician Services: Springfield, Chatham, Jacksonville,
Lincoln and Petersburg
- Mental Health Centers of Central Illinois: Springfield, Lincoln,
Jacksonville and Havana
Our pledge to You
We understand that health information about you is personal and are
committed to protecting health information about you. We create a
record of the care you receive to assure quality of care, for billing for
care and to comply with legal requirements. This Notice applies to
all of the records of your care that we maintain, whether created by
facility staff or your personal doctor. Your personal doctor may have
different policies regarding the doctor’s use and disclosure of your
health information created in the doctor’s office. We are required by
- Keep health information about you private;
- Give you this Notice of our legal duties and privacy practices with
respect to health information about you; and
- Follow the terms of the notice of privacy practices that is currently
Changes to this Notice
We may change this Notice at any time. Changes will apply to health
information we already hold, as well as new information, after the
change occurs. Before we make a significant change in our privacy
practices, we will change this Notice and post the new Notice in
the front entrances of our locations and on our Web site (www.
How We May Use and Disclose Your Health
Information without Your Written Authorization
The following items describe different categories of uses and
disclosures of your health information that we may make without
your written authorization. We have provided an example for each
category, but have not listed every kind of use or disclosure within
the category. We will ask for your written authorization for certain
other categories of uses and disclosures of your health information,
which are described below under the section entitled "Other Uses
and Disclosures of Health Information."
- For treatment, such as disclosing your health information to your
doctors, nurses and others involved in your health care to provide
and manage your care. We also may contact you for appointment
reminders, or to tell you about or recommend possible treatment
options, alternatives, health-related benefits or services that may
be of interest to you.
- For payment, such as creating bills for your care and collecting
payment for your care.
- For healthcare operations, such as administration, management,
business planning and other operations of the hospital.
- To legal representatives, such as to your parents if you are
younger than 18 years old.
- To persons involved in your care or payment for care, such
as to a family member or friend identified by you, if the disclosure
is related to the person’s involvement. In these situations, we
will give you a chance to object to the disclosure unless you are
unconscious or otherwise unable to object and we believe the
disclosure is in your best interests.
- For our patient directory, to let visitors know your location in
the hospital and general condition and also to let clergy know your
- As required by law, such as where we must disclose information
to comply with a federal, state or local law.
- For public health purposes, such as to the government to
report a birth or death or suspected child abuse or neglect.
- For health oversight activities, such as to government
or private agencies as part of an audit or inspection by a
government agency which issues our license.
- For organ and tissue donation, such as where a patient has
died or is near death and may be a candidate for organ donation.
- For disaster relief, such as to an organization helping with
disaster relief so that your family can be told about your
condition, status and location.
- For worker’s compensation purposes, such as to comply with
the Illinois worker’s compensation law or similar programs that
provide benefits for work-related injuries or illness.
- For fundraising purposes, we may use and disclose limited
information about you (including your name, address, phone
number and dates on which you received care from us) to our
affiliated fundraising organizations;
- For lawsuits and disputes, such as in response to a valid court
order or subpoena.
- For law enforcement, such as to respond to a law enforcement
official’s request to help locate a suspect or witness or to alert
law enforcement to a death that may be the result of a crime.
- To avert a serious threat to health or safety, such as in order
to prevent or lessen a serious threat to the health and safety of
you, the public or another person.
- To correctional institutions, such as to a correctional
institution at which you are an inmate in order to protect your
health and safety or that of others.
- For military and veteran activities, such as disclosing health
information about a member or veteran of the armed forces to
appropriate military authorities.
- For national security and intelligence activities, such as
to federal officials for intelligence and other national security
activities authorized by law.
- For protective services for the president and other officials,
such as to authorized federal officials for the purpose of
protecting the president or foreign heads of state.
- For disclosures about a person who has died or is near
death, such as to a funeral director for funeral arrangements or a
coroner or medical examiner to identify a person who has died.
Other Uses and Disclosures of Health Information
For any category of use or disclosure that is not described above
or authorized by law, we must obtain your written authorization. If
you give us your written authorization, you may revoke (cancel) it
at any time by submitting a written revocation to our Privacy Office
at the address below or to the department, office or other location
that originally received your authorization. Your revocation will be
effective except to the extent that we have already acted upon it. We
will obtain your written authorization for the following categories of
use and disclosure:
- Highly Sensitive Information. Federal and state law may
require us to obtain your written authorization to disclose highly
sensitive health information under certain circumstances. Highly
sensitive health information is health information that is: (1)
in a therapist’s psychotherapy notes; (2) about mental illness
or developmental disabilities; (3) in alcohol and drug abuse
treatment program records; (4) in HIV/AIDS test results; (5)
about genetic testing; or (6) about sexual assaults. Sometimes
the law even requires us to obtain a minor patient’s authorization
to disclose this highly sensitive information to a parent or
- Research. If required by law or our committee which oversees
our research activities, we will obtain your written authorization
before using or disclosing your health information for research
- Marketing. We will obtain your written authorization before
using patient information about you to send you any marketing
materials. However, we may provide you with marketing
materials in a face-to-face encounter or give you a promotional
gift of minimal value without your authorization. We may also
communicate with you about products or services relating to
your treatment, care settings or alternative therapies without
your written authorization.
Rights Concerning Your Health Information
You have the following rights concerning your health information. Please
submit any requests in writing to the Privacy Office or call for an address
for the following locations.
- Passavant Area Hospital
701 North First Street
Springfield, IL 62781
Attention: Medical Records
- Abraham Lincoln Memorial Hospital
200 Stahlhut Dr.
Lincoln, IL 62656
Attention: Medical Records
217-732-2161 Ext. 75451
- Taylorville Memorial Hospital
201 East Pleasant Street
Taylorville, IL 62568
Attention: Medical Records
- Memorial Home Services - Home
Equipment and Private Duty
720 North Bond
Springfield, IL 62781
Attention: Manager Quality and Safety
- Memorial Physician Services
Koke Mill Medical Associates/Springfield
Clinic Manager 217-862-0800
Family Medical Center/Chatham
Clinic Manager 217-483-3487
Women's Healthcare Springfield
Clinic Manager 217-757-7932
Capitol Healthcare Medical Associates
Clinic Manager 217-528-0307
Jacksonville Pediatric Associates
Office Manager 217-245-5437
Family Medical Center/Lincoln
Clinic Manager 217-732-9681
Menard Medical Center/Petersburg
Clinic Manager 217-632-7761
Jacksonville Family Medical Associates
Clinic Manager 217-243-7200
Tara Ramsey MD/Jacksonville
Office Coordinator 217-479-0290
Jacksonville Family Practice
Office Coordinator 217-243-9471
David Coultas MD/Jacksonville
Office Coordinator 217-245-1421
Michelle Colen, MD/Jacksonville
Office Coordinator 217-243-7700
North Dirksen Medical Associates/Springfield
Office Coordinator 217-588-7400
South Sixth Medical Associates/Springfield
Office Coordinator 217-588-7450
- Mental Health Centers of Central Illinois
Administrator, Administrative Services
710 North Eighth Street
Springfield, IL 62702
- Looking at Records. In most cases, you may look at or get a copy of
treatment or billing records. If you request copies, we may charge a
fee for the cost of copying and mailing them. If we deny your request,
you may submit a written request for a review of that decision.
- Amendments. If you believe that information in a treatment or billing
record is incorrect, you may request that we amend the record, by
submitting a written request that states your reason for requesting
the amendment. We may deny your request to amend a record if
the information was not created by us, if it is not part of the health
information maintained by us, or if we determine that the record is
accurate. You may appeal, in writing, a decision by us not to amend a
- Accounting. You may request a list called an “accounting” of certain
disclosures of health information about you, other than common
disclosures (such as for treatment, payment, health care operations or
where authorized by you). This list may be obtained by submitting a
written request, specifying the time period desired for the list, which
must be less than a 6-year period and starting after April 14, 2003.
You may receive the list in paper or electronic form. The first list
request in a 12-month period is free; other requests will be charged
according to our cost of producing the list. We will inform you of the
cost before you incur any costs.
- Confidential Communications. You may request that health
information about you be communicated to you in a certain way or
at a certain place, such as by sending mail to your work address. We
will agree to reasonable requests, but, if the request may result in
our not being paid for your care, then we may require you to provide
additional information about how payment will be handled.
- Additional Limits. You may request a limit on how we use or disclose
your health information for treatment, collecting payment or health
care operations or to persons involved in your care. We will consider
your request but are not required to accept it. We will inform you
of our decision on your request. If we agree, we will comply with
your request unless required by law, necessary to provide you with
emergency care or authorized by you.
- Copy of This Notice. You may get a paper copy of the current
version of this Notice at any time, even if you have agreed to receive
this Notice electronically. To do so you may contact the Privacy Office
at the address or phone number below. A current copy of this Notice
is also available on our Web site at www.memorialmedical.com.
If you are concerned that your privacy rights may have been violated,
or you disagree with a decision we made about your health information,
you may write to or call our Privacy Office or our Compliance and
Privacy AlertLine, a 24-hour phone service, at 1-800-541-9331. You may
also file a written complaint with the U.S. Department of Health and
Human Services – Office for Civil Rights. We honor your right to make a
complaint and will not take any action against you for filing a complaint.
Our Privacy Office can provide you the address of the Office of Civil