The Cofre Group, Inc. / dba The Ark Pediatric Compression Bracing                                           

NOTICE OF PRIVACY PRACTICES  

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

            If you/your child have any questions about this notice, please contact us at (847) 921.0899, The Cofre Group, Inc., P.O. Box 5224 Buffalo Grove, Il. 60089-5224.

Who will Follow This Notice

            This notice describes the information privacy practices followed by our employees, staff and other office personnel.

Your Health Information

            This notice applies to the information and records we have about your/your child‘s health, health status, and the services you/your child receive at this office.

            We are required by law to give you/your child this notice.  It will tell you/your child about the ways in which we may use and disclose health information about you/your child and describes your/your child’s rights and our obligations regarding the use and disclosure of this information.

How we may use and disclose health information about you/your child

For Treatment:           We may use health information about you/your child with medical treatment or services.  We may disclose health information about you/your child to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you/your child and your/your child’s health.

For example, this includes such things as verbal and written information that we obtain about you/your child and use pertaining to your/your child’s medical condition and treatment provided to you/your child by other medical personnel (including doctors and nurses who give orders to allow us to design a brace for you/your child).  It also includes information we give to other health care personnel (therapists) with whom we work in the process of designing a brace.

Different personnel in our office may share health information about you/your child and disclose information to people who do not work in our office in order to coordinate your/your child’s care, such as phoning your/your child’s therapist. Family members and other health care providers may be part of your/your child’s medical care outside this office and may require information about you/your child that we have.

For Payment:  We may use and disclose health information about you/your child so that the brace(s) and services you/your child receive from our company may be billed to and payment may be collected from you, an insurance company, or third party.  For example, we may need to give your/your child’s health plan information about the brace(s) you/your child received here so your/your child’s health plan will pay us or reimburse you/your child for the brace(s).  We may also tell your/your child’s health plan about a brace you/your child are going to receive to obtain prior approval, or to determine whether your/your child’s plan will cover the device.

For Health Care Operations:            We may use and disclose health information about you/your child in order to run the office and to make sure that you/your child and our other patients receive quality care.  For example, we may use your/your child’s health information to evaluate the performance of our staff in caring for you/your child.  We may also use health information about all or many of our patients to help us decide what additional service we should offer, how we can become more efficient, or whether certain new braces are effective.

Treatment Alternatives:        We may tell you/your child about or suggest you contact your/your child’s physician about possible treatment options or alternatives that may be of interest to you/your child.

SPECIAL SITUATIONS

We may use or disclose health information about you/your child without your/your child’s permission for the following purpose, subject to all applicable legal requirements and limitations.  

To Avert a Serious Threat to Health or Safety:      We may use and disclose health information about you/your child when necessary to prevent a serous threat to your/your child’s health and safety or the health and safety of the public or another person.

Required by Law:      We will disclose health information about you/your child when required to do so be federal, state or local law.

Research:       We may use and disclose health information about you/your child for research projects that are subject to a special approval process.  We will ask you/your child for your/your child’s permission if the researcher will have access to your/your child’s name, address or other information that reveals who you/your child are, or will be involved with your/your child’s care at the office.

Military, Veterans, National Security, and Intelligence:    If you/your child are or were a member of the armed forces, or part of national security or intelligence communities, we may be required by military command or other governmental authorities to release health information about you/your child.  We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation:      We may release health information about you/your child for workers’ compensation or similar programs.  These programs provide benefits for work related injuries or illness.

Public Health Risks:  We may release health information about you/your child for public health reasons in order to prevent or control disease, injury or disability, or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Lawsuits and Disputes:         If you/your child are involved in a lawsuit or dispute, we may disclose health information about you/your child in response to a court or administrative order, subject to all applicable legal requirements, we may also disclose health information about you/your child in response to a subpoena.

Coroners, Medical Examiners and Funeral Directors:       We may release health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or to determine the cause of death.

Information Not Personally Identifiable:      We may use or disclose health information about you/your child in a way that does not personally identify you/your child or reveal who you/your child are. 

Family:  We may disclose health information about you/your child to your/your child’s family members if we obtain your/your child’s verbal agreement to do so or if we give you/your child an opportunity to object to such a disclosure and you/your child do not raise an objection.  We may also disclose health information to your/your child’s family if we can infer from the circumstances, based upon our professional judgment that you/your child would not object.  For example, we may assume you/your child agree to our disclosure of your/your child’s personal health information to your spouse when you bring your spouse with you into the room during your/your child’s appointment for design/measurement for the brace. In order to disclose health information about you/your child to friends we would need a written, signed authorization.  

Other Uses and Disclosures of Health Information:          

We will not use or disclose your/your child’s health information for any purpose other than those identified in the previous sections, without your/your child’s specific, written authorization.  We must obtain your/your child’s authorization separate from any consent we may have obtained from you/your child.  If you/your child give us Authorization to use or disclose health information about you/your child, you/your child may revoke that authorization, in writing, at any time.  If you/your child revoke authorization, we will no longer use or disclose information about you/your child for the reasons covered by written authorization, but we can not take back any uses or disclosures already made with your/your child’s permission.

If we have HIV or substance abuse information about you/your child, we cannot release that information without a special, signed authorization (different than the Authorization and Consent mentioned above) from you/your child.  In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your/your child’s signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.

Your/your child’s Rights Regarding Health Information About You/your child:   

You/your child have the following rights regarding health information we maintain about you/your child.

Right to Amend:         If you/your child believe health information we have about you/your child is incorrect or incomplete, you/your child may ask us to amend this information.  You/your child have the right to request an amendment as long as the information is kept by this office.

To request an amendment, complete and submit a Medical Record Amendment/Correction Form to Privacy Officer.  We may deny your/your child’s request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your/your child’s request if you/your child ask us to amend information that:

a.         We did not create, unless the person or entity that created the information is no longer available to make the amendment;

b.                  Is not part of the health information we kept;

c.                   You/your child would not be permitted to inspect and copy;

d.                  Is accurate and complete.

Right to an Accounting of Disclosures:        You/your child have the right to request an “accounting of disclosures”.  This is the list of the disclosures we made of medical information about you/your child for purposes other than treatment, payment or other health care operations.  To obtain this list, you/your child must submit your/your child’s  

request in writing to Privacy Officer.  It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.  Your/your child’s request should indicate in what form you/your child want the list (for example, on paper, electronically).  We may charge you/your child for the costs of providing the list.  We will notify you/your child of the costs involved and you/your child may choose to withdraw or modify your/your child’s request at that time before any costs are incurred.

Right to Request Restrictions:         You/your child have the right to request a restriction or limitation on the health information we use or disclose about you/your child for treatment, payment or health care operations.  You/your child also have a right to limit the health information we disclose about you/your child to someone who is involved in your/your child’s care or the payment for it, like a family member or friend.  For example, you/your child could ask that we not use or disclose information about a surgery you/your child had.

We are Not Required to Agree to Your/your child’s Request:       If we do agree, we will comply with your/your child’s request unless the information is needed to provide you/your child emergency treatment.

To request restrictions, you/your child may complete and submit the Request for Restriction On Use/Disclosure of Medical Information to Privacy Officer.

Right to Request Confidential Communications:     You/your child have the right to request that we communicate with you/your child about medical matters in a certain way or at a certain location.  For example, you/your child can request that we only contact you/your child at work or by mail.  

To request confidential communications, you/your child may complete and submit the Request for Restriction on Use/Disclosure of Medical Information And/Or Confidential Communications to Privacy Officer.  We will not ask you/your child the reason for your/your child’s request.  We will accommodate all reasonable requests.  Your/your child’s request must specify how or where you/your child wish to be contacted.

Right to a Paper Copy of This Request:      You/your child have the right to a paper copy of this notice.  You/your child may ask us to give you/your child a copy of this notice at any time.  Even if you/your child have agreed to receive it electronically, you/your child are still entitled to a paper copy.  To obtain such a copy, contact Privacy Officer.

Changes to This Notice:       

We reserve the right to change this notice, and make the revised or changed notice effective for medical information we already have about you/your child as well as any information we receive in the future.  We will post a summary of the current notice in the office with its effective date in the top right hand corner.  You/your child are entitled to a copy of the notice currently in effect.

Complaints:    If you/your child believe your/your child’s privacy rights have been violated, you/your child may file a complaint with our office or with the Secretary of the Department of Health and Human Services.  To file a complaint with our office, contact Privacy Officer.  You/your child will not be penalized for filing a complaint.

Effective Date of This

Notice: Aprirl 14, 2003