A D MEDICAL SUPPLY, INC.
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

Summary of Our Privacy Practices

For purposes of this notice, “A D Medical Supply, Inc.” and the pronouns “we,” “us” and “our” refer to all of the health care suppliers operated or managed by A D Medical Supply, Inc. and/or its subsidiaries. These entities have been designated as a single affiliated covered entity for HIPAA Privacy Rule purposes. We may use and disclose your medical information, without your permission, for treatment, payment, and health care operations activities and, when required or authorized by law, for public health and interest activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

We may disclose your medical information to your family members, friends, and others you involve in your health care or payment for health care, and to appropriate public and private agencies in disaster relief situations.

We will not otherwise use or disclose your medical information without your written authorization.

You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures we may make of your medical information, and to request that we amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information. Please review this entire notice for details about the uses and disclosures we may make of your medical information, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

Our Legal Duty

We are required by state and federal law, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), to maintain the privacy of your medical information. We are also required to inform you of our privacy practices, our legal duties, and your rights in relation to the medical information that we maintain about you. We will follow the practices that are described in this Notice while it is effective. This Notice is effective as of April 14, 2003 and will remain in effect unless we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. If we significantly change in our privacy practices, we will change this Notice, and make the new notice available to our patients and others upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information at the end of this Notice.

YOUR PROTECTED MEDICAL AND HEALTH INFORMATION

When you receive care from a healthcare provider, a record is made of that treatment. This record will typically contain information about your diagnosis, treatment, and future plan of treatment and is often collectively referred to as your medical record. This medical record includes your medical and health information and lays the foundation for determining your plan of care and treatment and allows for a successful means of communication between all healthcare professionals that contribute to your care. HIPAA protects information found in your medical record from improper use and disclosure. The information protected by HIPAA includes:

  • Any information related to your past, present or future physical or mental health;
  • The past, present or future payment for health services you have received;
  • The specific care that you have received, are receiving or will receive;
  • Any information that identifies you as the individual receiving the care; and
  • Any information that someone could reasonably use to identify you as receiving the care.

This information is collectively referred to as your medical information throughout this Notice.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION—TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

Treatment – We may use and disclose your medical information, without your permission, to treat you. As it pertains to A D Medical Supply, Inc. and its health care supplier subsidiaries and affiliates, treatment includes supplying you drugs, medications, supplies, durable medical equipment, and Medical Nutritional Therapy, as ordered by your physician. Treatment also includes coordination and consultation with your physician and other health care providers. As we provide these services to you, information obtained during this process will be recorded in your medical record. We will use this information, in coordination with your physician, to determine the best course of treatment for you.

Payment – We may use and disclose your medical information, without your permission, to obtain reimbursement for health care products and services that we provide to you, including submitting claims to health plans, other insurers, payers, or others. Payment activities include actions required for us to obtain reimbursement from your insurance carrier for the products and services ordered by your physician and provided to you by us. The activities include eligibility determinations, pre-certifications, billing and collection activities, obtaining documentation required by your insurer, and when applicable, disclosure of information to consumer reporting agencies.

Health Care Operations – We may use and disclose your medical information, without your permission, for health care operations. Health care operations may include:

  • Review of your medical information by our professional healthcare staff to ensure compliance with all federal and state regulations;
  • Utilization of your medical information to continually improve the quality and effectiveness of the services DCC provides to you; and
  • Our business management and general administrative activities.

You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. You may revoke such authorization at any time. However, your revocation will not affect any use or disclosure previously permitted by your authorization. Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those permitted by law and as described in this Notice.

OTHER PERMITTED USES AND DISCLOSURES

We may use and disclose your medical information without your authorization for purposes other than treatment, payment or health care operations in certain circumstances.

Family, Friends and Others Involved in Your Care or Payment for Care

We may disclose to a member of your family, other relative, or a close personal friend, or any other person identified by you, your medical information directly relevant to such person's involvement with your care or payment related to your health care.

Public Health and Benefit Activities

We may use and disclose your medical information to third parties, without your authorization, if it is:

  • Required by law;
  • For certain public health activities and purposes;
  • To a legally-authorized government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence;
  • For law enforcement purposes and in response to court orders or subpoenas; or
  • To agencies authorized by law to conduct health oversight activities, including audits, investigations, licensing and similar activities

YOUR RIGHTS AS OUR PATIENT

You have the following rights in relation to your medical information:

Restriction - you may request, in writing, that we restrict our use or disclosure of your medical information. We are not required to agree to the requested restrictions. If we do agree, we will abide by our agreement, except in emergencies or as required or authorized by law. If you would like us to restrict our use or disclosure of your medical information, you should submit your request to the contact office listed on this Notice.

Amendments - you have the right to request that we amend your medical record. Your request must be in writing and it must explain why the information should be amended. You should submit your request to the contact office listed on this Notice. We may deny your request only for certain reasons. If we deny your request, we will provide you with a written explanation. If we accept your request, we will make your amendment part of your medical information and will use reasonable efforts to inform others of the amendment who we know may have relied upon the unamended information to your detriment, as well as persons who you want to receive the amendment.

Electronic Notice - if you obtained a copy of this Notice on our website or by electronic mail (email), you are entitled to receive a copy of this Notice in written form. Please contact us using the contact information at the end of this Notice to obtain a copy of this Notice in written form.

Access - You have the right to inspect and obtain a copy of your medical record, subject to certain limitations. You must make a written request to obtain copies of your medical information. You should submit your request to the contact office at the end of this Notice.

We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact us using the information at the end of this notice for information about our fees.

Accounting of Disclosures - you have the right to obtain an accounting of disclosures of your medical record for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities. You should submit your request to the contact office at the end of this Notice. We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional requests. Contact us using the information at the end of this Notice for information about our fees.

Confidential Communications - you have the right to request that we communicate with you about your medical information in confidence by alternative means or to alternative locations that you specify. You should submit your request to the contact office at the end of this Notice.

We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communication, and explains how payment for our services will be handled under the alternative means or alternative location you request for confidential communication of your medical information. We will not ask you to explain the reason for your request.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions, would like additional information or, if you suspect misuse of your protected health information and believe that your rights have been violated, you may, without fear of retaliation, contact:

A D Medical Supply, Inc.
1525 W. Homer Street, Suite 101
Chicago, IL 60642
Attn: Cory D. Skwor
General Manager/Owner
Phone: 1-888-785-7370
Email: info@admedicalinc.com


You may also file a complaint with:

Office for Civil Rights
U.S. Department of Health & Human Services 200 Independence Avenue SW
HHH Building, Room 509F
Washington D.C. 20201
(800) 368-1019