Notice of Health Information Practices | Website Policies & Procedures
Patient Rights and Responsibilities | Illinois Community Benefits Act
Notice of Health Information 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.
Understanding Your Health Record/Information
Each time you visit NorthShore University HealthSystem (NorthShore) a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment and a plan for future care or treatment. This information is often referred to as your health or medical record.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information
- Obtain a paper copy of this notice of health information practices
- Inspect and obtain a copy of your health record
- Request an amendment to your health record
- Obtain an accounting of disclosures of your health information
- Request communications of your health information by alternative means or at alternative locations
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
This organization is required to:
- Maintain the privacy of your health information
- Provide you with a 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 health information by alternative means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post the revised notice and publish the revision on our web site. We will not use or disclose your health information without your authorization, except as described in this notice.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact Concierge Services at 224.364.4968. We respect your right to privacy. If you believe your privacy rights have been violated, you may file a complaint with Concierge Services or with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health Operations
We will use your health information for treatment.
We will provide your physician, the hospital or a subsequent healthcare provider with copies of various reports from your medical record that should assist him or her in treating you.
We will use your health information for payment.
A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health operations.
Members of the professional staff, 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.
Other Disclosures permitted without authorization WITH opportunity to agree or object:
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person of your choice, your location, and general condition.
Facility Directory: Patients will be listed in the hospital directory with disclosure to persons who ask for the individual by name. Only the patient’s name, location in the facility and condition in general terms will be disclosed unless the patient opts out of this listing at the time of registration.
Clergy: Patients will be listed on the religious census available to community clergy or designated representatives unless the patient opts out of this listing at the time of registration or upon follow up from the hospital clergy.
Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment for health care.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We do not rent or sell patient information. If a patient wishes to opt out of receiving further information they may call the Marketing Department at 847.570.3187.
Fund raising: We may contact you as part of a fund-raising effort. If you prefer not to receive fundraising letters from us, please let us know by contacting the NorthShore University HealthSystem Foundation at 224.364.7200.
Other Disclosures permitted without authorization and WITHOUT opportunity to agree or object:
Business associates: There are some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do. To protect your health information, however, we require all business associates to appropriately safeguard your information.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy or your health information.
Coroner, Funeral Director and Organ procurement organizations: We may disclose personal health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose personal health information to a funeral director as authorized by law in order to permit the funeral director to carry out their duties. 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 tissue donations and transplant.
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.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities relating to the oversight of the healthcare system.
Workers compensation: We may disclose health information to the extent authorized by and to the extent 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. Report vital events such as birth or death, as well as, other occurrences when required by Illinois Stat Law.
Report of abuse, neglect or Domestic Violence: We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law.
Specified Government Functions: In certain circumstances, the Federal regulations authorize the provider to use or disclose your protected health information to facilitate specified government functions.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena
Effective Date: April 14, 2003
Website Policies & Procedures
The information presented on northshore.org is not intended to replace the advice of a doctor, rather to help inform our users on health issues. The information found on this site should be used as a supplement to the learning process, not as a diagnostic tool. If you have an immediate medical need, please contact your physician or local emergency medical service.
At NorthShore University HealthSystem, we value your privacy above anything else. That is why we will never share any personal information that can be used to identify you as a user (either registered or non-registered) with an outside company without your explicit consent. Furthermore, we pride ourselves on maintaining HIPAA compliancy 7 days a week, 24 hours a day, 365 days a year.
What you should expect from us:
- We will strive to maintain your privacy, confidentiality, and security at all times.
- It is our goal to ensure your trust and confidence by providing you with as much information as we can about data collection procedures and information when needed.
- We will not intentionally use your data without your permission, unless for purposes of maintaining the site or for reviewing the site's use.
- We will make every effort to notify you accordingly of all data collection practices.
- It is our intention to clearly inform you when your risks or privacy may change during the course of using this site.
- We want you to know that this system operates on a secure server and your financial and professional information and health-related personal information is encrypted before it is transmitted. Encryption is a form of scrambling and de-scrambling that ensures that no unauthorized person can see your information.
- We will not accept or show you health information content, advertising, sponsored programs, or services that we know to contain false or misleading information or that promote ineffective or dangerous products.
Our Security Measures
We want your personal information to remain as secure as possible; our business depends on it. We use encryption practices to help insure the integrity and privacy of the personal information, fiancial and/or health-related personal information you provide to us. As an added security precaution, all personal information and/or health-related personal information are kept on servers with firewalls that meet or exceed industry standards to prevent intruders from gaining access. Although we make every reasonable effort to protect personal information and health-related personal information from loss, misuse, or alteration by third parties, you should be aware that there is always some risk involved in transmitting information via the Internet and that hackers or thieves do find ways to thwart security systems.
Our Editorial Policy outlines the evaluation process all health information content goes through. We want you to rely on us as a trustworthy, quality resource of health information. Medical experts have reviewed the content on this site for clinical accuracy. You'll have information on who wrote an article and when it was written and updated.
Third-Party Content and Linked Sites
NorthShore University HealthSystem (NorthShore) will at times provide links on its web site (northshore.org) to third party web sites (linked sites). While every effort is made to ensure the content of these linked sites is accurate, appropriate and relevant, NorthShore does not endorse, guarantee or accept any responsibility for the content on linked sites. Access to linked sites is subject to the terms and conditions of those sites. Users are urged to take necessary precautions to protect themselves against malicious sites which can contain viruses, spyware, phishers etc.
NorthShore.org features content on its site provided by third-party vendors as indicated in the body of these pages. This content is provided for reference only and should not be used as a replacement for professional medical advice and/or treatment. You should always contact your doctor for specific advice on your care.
Patient Rights and Responsibilities
We believe that our patients receive the best possible care when they participate with our medical staff in their medical treatment. Toward that goal, please be aware of your rights and responsibilities when you are a patient at a NorthShore facility, or when you are the parent, guardian or legally authorized decision maker of a patient.
Your Rights as a Patient
Access to Care, Transfer, and Continuity of Care
You will have access to medical treatment, care, and services that are available or medically indicated, regardless of race, creed, sex, national origin, or source of payment. You will not be transferred to another facility or organization unless you receive a complete explanation of the need for the transfer. You will be informed of any continuing healthcare requirements.
Respect and Dignity
You have the right to considerate, respectful care at all times and under all circumstances, with recognition of your personal dignity. You have the right to have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected. You have the right to be free from mental, physical, sexual, and verbal abuse; neglect; and exploitation.
If you have provided us with a copy of your advance directive, we will honor your expressed wishes and directives as fully and as reasonably possible, and in accordance with Illinois law. Your access to care, treatment, and services, however, is not dependent upon whether or not you have an advance directive.
You have the right, within the law, to privacy and confidentiality during your stay. This includes: discreet discussion or consultation of your case among those directly involved or who are present with your permission; access to your medical record limited to those directly involved with your treatment; or with monitoring its quality or with your expressed permission; and to have your personal privacy and modesty respected as much as possible when being treated and examined.
Your Medical Record
You have the right to access, review and get copies of your medical record. You have a right to request amendments to your medical record in accordance with our policies. Except where permitted by law, your medical record cannot be released without your consent. You have a right to receive an accounting of any disclosures regarding you health information.
You have the right to complete and current information about your diagnosis, treatment, pain management and prognosis when it is known. In cases when it is not medically advisable to provide such information to you, we will provide that information to a legally authorized individual. You and, when appropriate, your family or legally authorized decision maker, have a right to be informed about the outcomes of care, including unanticipated outcomes. You have the right to know the identity and professional status of people providing service to you and to know which physician or practitioner is responsible for your care. You also have the right to information on any relationship which may suggest a conflict of interest which may affect your care. You have the right to be informed of policies applicable to conduct as a patient in addition to the mechanism for the initiation, review, and resolution of complaints. You also are entitled to an itemized explanation of your bill for any services rendered at a NorthShore facility. If you or your family have hearing, speech or language difficulties, Interpretive Services are available for you and your family members. Contact your nurse for details.
If you are admitted to one of our hospitals, you have the right to visitors and a right to communicate verbally and in writing with people outside the Hospital, including state regulatory agencies.
You or your legally authorized decision maker have the right to participate in decisions about your treatment. You should receive a clear and concise explanation of your condition and all proposed technical procedures, including any medically significant alternatives of care or treatment. Whenever possible, this explanation will include a discussion of the risk of death or of serious side effects, problems of recuperation, probabilities of success, alternatives to the proposed plan, and possible consequences if you choose to forgo treatment.
Acceptance and Refusal of Treatment
To the extent permitted by law and regulation, you or your legally authorized decision maker have the right to accept or to refuse medical or surgical treatment, care, or services including foregoing or withdrawing life-sustaining treatment or withholding resuscitative services. You also have the right to additional consultation at your own expense. You or your legally authorized decision-maker have the right to refuse to participate in research programs.
Access to Pain Management
In cooperation with your physician, you have the right to appropriate assessment and management of pain. As appropriate, and as identified as part of your treatment, you will be educated about the pain assessment process and in ways that you can actively participate in the management of your pain. To achieve optimal pain management, it is important to communicate your pain management needs with your physician and others responsible for your care.
Access to Protective Services
If you believe that you are in need of protective services or have been identified as a possible victim of abuse or neglect, you have the right to receive protective services that are consistent with your needs. Ask your nurse to contact a social worker to assist you.
Your Responsibilities as a Patient
Following Rules and Regulations
You have the responsibility to abide by the rules and regulations of the NorthShore facility, including observing our non-smoking policy.
You have the responsibility, to the fullest extent possible, to completely and accurately provide your healthcare provider with all the information that may affect the care you receive, including your Advance Directives document. You and your family are responsible for reporting any perceived risks that may affect your care and unexpected changes in your condition.
Complying with Treatment Plans and Following Instructions
You are responsible for complying with the treatment plans provided by your caregivers and with instructions for your care. If you do not understand the instructions or do not understand what you are expected to do, you should ask your caregivers for an explanation. If you do not follow the instructions given to you, you are responsible for the consequences and for the outcomes of the services or the treatment plan.
Showing Respect and Consideration
You and your family are responsible for being considerate of the NorthShore facility personnel and property and for being considerate of the needs of other patients by helping to control noise and other disturbances.
Meeting Financial Commitments
You are responsible for promptly meeting any financial obligations agreed to with NorthShore University HealthSystem.
If you would like to express a concern or complaint about your care or safety please speak to your caregiver, the department director or manager. You are also welcome to call Concierge Services at 224.364.4968 for assistance. If the hospital is unable to provide resolution that you consider to be satisfactory, you may contact The Joint Commission by either calling 800.994.6610 or emailing firstname.lastname@example.org. The Illinois Department of Public Health can also be reached at 800.252.4343; TTY call 800.547.0466.
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Patient Rights and Responsibilities - English
For information on Advance Directives including health care power of attorney, living wills, mental health treatment preference declarations, and do-not-resuscitate orders visit the State of Illinois website.
Illinois Community Benefits Act
This hospital annually files a report of its community benefit plan with the Illinois Attorney General's Office. This report is public information and available to the public by contacting:
CHARITABLE TRUSTS BUREAU
OFFICE OF THE ATTORNEY GENERAL
100 West Randolph Street, 3RD Floor
Chicago, Illinois 60601-3175
Required by Section 20(c) of Public Act 093-0480