GLASS MOUNTAIN CAPITAL LLC
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 have any questions about this notice, please contact Debbie Ortiz HIPAA Compliance Director
Glass Mountain Capital LLC, 1375 E Woodfield Road, Ste. 400, Schaumburg, IL 60173
Phone: (800) 265-3796, ext. 203
We are required by law to:
- Maintain the privacy of protected health information
- Give you this notice of our legal duties and privacy practices regarding health information about you
- Follow the terms of our notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you (“Personal Health
Information"). Except for the purposes described below, we will use and disclose Personal Health Information only
with your written permission. You may revoke such permission at any time by writing to our HIPAA Compliance
For Payment. We may use and disclose Personal Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.
As Required by Law. We will disclose Personal Health Information when required to do so by international, federal,
state or local law.
Business Associates. We may disclose Personal Health Information to our business associates that perform
functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are
obligated to protect the privacy of your information and are not allowed to use or disclose any information other than
as specified in our contract.
Workers' Compensation. We may release Personal Health Information for workers' compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
Health Oversight Activities. We may disclose Personal Health Information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your Personal Health Information to provide legally
required notices of unauthorized access to or disclosure of your health information.
You have the following rights regarding Personal Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Personal Health Information that may be used to make decisions about payment for your care. This includes medical and billing records, other than psychotherapy
notes. To inspect and copy this Personal Health Information, you must make your request, in writing, to the medical
records department of the original provider. There may be a reasonable fee for the costs of copying, mailing or other supplies associated with your request. The provider may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs based benefit program. The provider may deny your request in certain limited circumstances.
Right to an Electronic Copy of Electronic Medical Records. If your Personal Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Personal Health Information in the form or format you request, if it is readily producible in such form or format. If the Personal Health Information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Personal Health Information.
Right to Amend. If you feel that Personal Health Information we have is incorrect or incomplete, you may ask the original provider to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to original provider of services.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Personal Health Information for purposes other than payment for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Debbie Ortiz HIPAA Compliance Director, Glass Mountain Capital LLC, 1375 E Woodfield Road, Ste. 400, Schaumburg, IL 60173.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Personal Health Information we use or disclose for payment. For example, you could ask that we not share information about a particular diagnosis or treatment. To request a restriction, you must make your request, in writing, to Debbie Ortiz HIPAA Compliance Director, Glass Mountain Capital LLC, 1375 E Woodfield Road, Ste. 400, Schaumburg, IL 60173
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Personal Health Information with respect to that item or service not be disclosed to a health plan and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with you about matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Debbie Ortiz
HIPAA Compliance Director, Glass Mountain Capital LLC, 1375 E Woodfield Road, Ste. 400, Schaumburg, IL 60173. Your request must specify how or where you wish to be contacted. We will accommodate your request.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.glassmountaincapital.com.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Personal Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice on our website and in our office. The notice will contain the effective date on the first page.
If you believe your privacy rights have been violated, you 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 David Ansani, Glass Mountain Capital LLC, 1375 E Woodfield Road, Ste. 400, Schaumburg, IL 60173.
All complaints must be made in writing.
You will not be penalized for filing a complaint.