NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective Date: April 14, 2003
We respect client confidentiality and only release protected health information about you in accordance with the Illinois and
federal law. This notice describes our policies related to the use of the records of your care generated by Pioneer Center.
Privacy Contact. If you have any questions about this policy or your rights contact the Privacy Contact, (815) 344-1230 or
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment,
payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your
rights regarding protected health information we maintain about you and a brief description of how you may exercise these
rights. This Notice further states the obligations we have to protect your health information.
“Protected health information” (PHI) means protected health information (including identifying information about you) we have
collected from you or received from your health care providers, health plans, your employer or a health care clearinghouse. It
may include information about your past, present or future physical or mental health or condition, the provision of your health
care, and payment for your health care services.
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of our
legal duties and privacy practices with respect to your protected health information. We are also required to comply with the
terms of our current Notice of Privacy Practices.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
In order to effectively provide you care, there are times when we will need to share your protected health information with
others outside our agency. We will obtain your written consent to do so. This includes:
Treatment. We may use or disclose protected health information about you to provide, coordinate, or manage your care or any
related services, including sharing information with others outside our agency that we are consulting with or referring you to.
We may release your telephone number to an agency for follow up calling after you are discharged from services at Pioneer
Center for Human Services, for purposes of surveying customer satisfaction with our services.
Payment. Information will be used or disclosed to obtain payment for the treatment and services provided. This will include
contacting your health insurance company for prior approval of planned treatment or for billing purposes.
Healthcare Operations. We may use information about you to coordinate our business activities. This may include setting up
your appointments, reviewing your care, and/or training staff.
Information Disclosed Without Your Consent. Under Illinois and federal law, information about you may be disclosed without
your consent in the following circumstances:
Emergencies. Sufficient information may be shared to address the immediate emergency you are facing.
Follow Up Appointments/Care. We will be contacting you to remind you of future appointments or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
As Required by Law. This would include situations where we have a subpoena, court order, or are mandated to provide public
health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or
institutional abuse. All subpoenas and search warrants are to be directed to 4031 W. Dayton St., McHenry, IL 60050 for receipt
by either the President/CEO or designated individual.
Coroners, Funeral Directors, and Organ Donation. We may disclose protected health information to a coroner or medical
examiner and funeral directors for the purposes of carrying out their duties. When organs are donated sufficient information will
be provided to the program as necessary to facilitate the organ or tissue donation.
Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as
audits, investigations, inspections and licensure. There also might be a need to share information with the Food and Drug
Administration related to adverse events or product defects. We are also required to share information, if requested with the
Department of Health and Human Services to determine our compliance with federal laws related to health care. If you are a
member of the armed forces, we may disclose your protected health information as required by military command authorities,
or to determine your eligibility for benefits provided by the Department of Veteran Affairs.
Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel, we may share information
with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an
immediate danger may occur to yourself or others.
Fundraising. As a non-profit provider of health care services, we need assistance in raising money to carry out our mission. We
may contact you to seek a donation. If you do not want us to contact you for fundraising purposes, you must notify the Privacy
Contact in writing. Please state clearly that you do not want to receive any fundraising solicitations from us.
Research. We may disclose your protected health information with your consent to researchers when their research has been
approved by an Institutional Review Board or a similar privacy board that has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information.
Genetic Information. Disclosure and/or use of genetic information without your consent is strictly prohibited.
Sale of PHI. The sale of PHI for which Pioneer Center receives any type of remuneration, directly or indirectly is strictly prohibited.
Marketing Purposes. PHI will not be shared by Pioneer Center for Human services for marketing purposes without your consent.
Uses and disclosures not described above in this Notice of Privacy Practices will only be made with your written permission, called
a “release”. You have the right to revoke a release at any time. If you revoke your release, we will not make any further uses or
disclosures of your health information under that release, unless we have already taken an action relying upon the uses or
disclosures you previously authorized.
You have the following rights under Illinois and federal law:
Copy of Record. You are entitled to inspect the client record our agency has generated about you. We may charge you a
reasonable fee for copying and mailing your record. We may disclose your PHI to you legal guardian or to your parent whether
custodial or non-custodial. If you are 12 years old or older, you must give consent for this release. There may be exceptions to
this rule as allowed by law which would permit us to share this information with guardians or parents without your consent.
Release of Records. You may consent in writing to release your records to others, for any purpose you choose. This could include
your attorney, employer, or others who you wish to have knowledge of your care. Your release must be specific as to the
protected health information to be released. You may revoke this consent at any time, but only to the extent no action has been
taken in reliance on your prior authorization.
Contacting You. You may request that we send information to another address or by alternative means. We will honor such
request as long as it is reasonable, and we are assured it is correct. We have a right to verify that the payment information you
are providing is correct.
Amending Record. If you believe that information in your record is incorrect or incomplete, you may request we amend it. To
do this contact the Privacy Contact and ask for the Request to Amend Health Information form. In certain cases, we may deny
your request. If we deny your request for an amendment you have a right to file a statement that you disagree with us. We will
then file our response and your statement, and these documents will be added to your record.
Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your protected health
information, except for information we used for treatment, payment, or health care operations purposes or that we shared with
you or your guardian, or information that you gave us specific consent to release. It also excludes information we were required
to release. To receive information regarding any disclosures made for a specific time period no longer than six years and after
April 14, 2003, please submit your request in writing to the Privacy Contact.
Questions and Complaints. If you have any questions, with a copy of this policy or have any complaints you may contact the
Privacy Contact in writing at our office for further information. You also may complain to the Secretary of Health and Human
Services or one of the agencies listed below if you believe our agency has violated your privacy rights. We will not retaliate against
you for filing a complaint.
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019
Equip for Equality
P.O. Box 276
Springfield, IL 62705
Guardianship & Advocacy
421 E. Capitol, Ste. 205
Springfield, IL 62701
Guardianship & Advocacy
State of Illinois Building
60 N. LaSalle, Ste. S-500
Chicago, IL 60601
Department of Children & Family Services
James R. Thompson Center
100 W. Randolph Street
Chicago, IL 60601
in state and federal law.
Confidentiality of Patient Records
Personal information about you and the services you receive is private and may be shared with someone else only
as allowed by the Illinois Mental Health code including chapter 2 and the Developmental Disabilities Confidentiality
The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal
law and regulations. Generally, the program may not say to a person outside the program that a patient attends
the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:
1. The patient consents in writing or
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to a qualified personnel for
research, audit, or program evaluation; or
4. The patient commits or threatens to commit a crime either at the program or against any person who
works for the program.
Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to the
United States Attorney in the district where the violation occurs.
Federal law and regulations do not protect any information about suspect child abuse or neglect from being
reported under state law to appropriate state or local authorities.