• I certify that the information that I have provided is correct to the best of my knowledge. I will not hold the Doctor or any staff member responsible for any errors or omissions that I may have made in the completion of this form.

    The law requires our medical practice (Suriya V. Sastri, M.D.) to protect the privacy of your medical information. This notice explains how our medical practice can use or share the medical information that our practice has about you or your family. It also explains your rights.

    For many people, third party insurance carriers, Medicare, or Public Aid (IDPA) pay for all health benefits and prescription drugs. Our medical practice must receive and keep your medical information so you can have these benefits. Our medical practice may contract with other organizations or individuals to help provide your health benefits. These contractors may also receive and keep your medical information

    Starting April14, 2003, we must follow this Notice until it is replaced. We can change the terms of this Notice at any time. If we change this Notice, we will send a new Notice to all persons enrolled at that time. We can make the new changes apply to all your medical information kept by us before and after the date of the new Notice. The Notice is posted at our medical office at 6900 Madison Street, Willowbrook, Illinois, 60527.

    We may use or share your medical information without your permission for the reasons below.

    • So, you can get medical care. For example, we may share your medical information with your doctor or pharmacy so that they can give you medical care and the right medicine.
    • So, medical bills can be paid. For example, we may use and share your medical information so your doctor can send a bill to your insurance carrier and so your insurance can pay your medical bills. We may also use or share your medical information to recover payment from other medical insurance or benefits you may have.
    • So, our medical practice can perform its duties. For example, we may use or share your medical information with the referring physicians and other physicians coordinating your medical care, to assess quality of care; to determine who is eligible for medical benefits; to manage your care, or for audits.
    • To tell you about other health services. For example, we may call or write to tell you about treatment options or other health-related services.
    • To comply with the law. For example, the law requires us to allow the U.S. Department of Health and Human Services or other related agencies to audit our records. We may share your medical information to comply with other laws. For other reasons. Examples include:
      • To comply with legal proceedings, such as a court or administrative order or subpoena
      • To enforce other laws or protect someone’s health and safety
      • So a family member, friend, or other person can help you to get or pay for your health care
      • So a personal representative you appoint or a court appoints for you can help you get health benefits
      • To support research, as long as the information will be protected by the researchers
      • So a coroner or medical examiner can identify a deceased person or cause of death or so a funeral director can arrange burial
      • To support an organ procurement organization in limited circumstances
      • To protect you against a serious threat to your health or safety or to the health or safety of others
      • To support a government agency or hospital overseeing health care or monitor disease incidence programs
      • For lawful national security purposes
      • For public health purposes
      • For military purposes, if you are a member of the armed forces.

    Our medical practice will not use or share your medical information for any other reason unless you give us written permission. You may withdraw your permission in writing at any time. However, if we have used or shared your information for a long-term project like a research study, we may continue to use or share your information for that purpose only. Your permission for us to use or share your information will end when our medical practice gets your written notice to withdraw you permission.

    Your Rights:

    You may ask our medical practice to do any of the following if you ask in writing. We will decide if it can do what you want it to do. We will write to tell you what it decides.

    • You may ask us not to use or share your medical information. We do not always have to agree.
    • You may ask us to contact you about your medical information privately in a different way or at a different place than we are currently doing. We do not always have to agree, unless the change is necessary to protect you, and we can still be paid for your medical bills. When you write to ask for this change, you must tell us how to contact you in private.
    • You may ask to see or get copies of your medical information. You may be charged a small fee for copies.
    • You may ask us to correct your medical information. We do not always have to agree to make the change.
    • You may ask for a list of the ways our medical practice or its contractors shared your medical information for up to 6 years. We can tell you this for information that it shared on or after April, 2003.
    • You may write to ask us to send you another copy of this Notice.

    If you want any of these things, contact our medical practice at the address below. We will help you make your written request.

    Complaints: If you believe our medical practice has not protected your right to privacy, you have the right to complain to us or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us at the address below. We will not hold it against you if you file a complaint.

    Privacy Officer: To get more copies of this Notice or more information about our privacy practices or your rights, or to file a complaint, contact the Privacy Officer at the following address:

    Suriya Sastri. MD
    6900 Madison Street
    Willowbrook, IL 60527