Privacy Statement



Effective January 1, 2012

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. Our practice uses health information about you for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of our practice.


For Treatment. Our practice may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as physicians, nurse, or other person providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and not how you respond to these actions.

For Payment. Our practice may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.

For Health Care Operations. Our practice may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to member of the medical staff, risk or quality improvement personnel, and others in order to:

  • evaluate the performance of our staff;
  • assess the quality of care and outcomes in your case and similar cases;
  • learn how to improve our facilities and services; and
  • determine how to continually improve the quality and effectiveness of the health care we provide

Appointments. Our practice may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Required by Law. Our practice may use and disclose information about as required by law. For example, our practice may disclose information for the following purposes:

  • for judicial and administrative proceedings pursuant to legal authority;
  • to report information related to victims of abuse, neglect or domestic violence; and
  • to assist law enforcement officials in their law enforcement duties.

Public Health. Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

Decedents. Health information may be used to funeral directors or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donations. Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.

Research. Our practice may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

Health and Safety. Your health information may be disclosed to avert a serious threat to health or safety of you or any other person pursuant to applicable law.

Government Functions. Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

Worker’s Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Worker’s Compensation.

Other Uses. Other uses and disclosures will be made only with your written authorization, and you may revoke the authorization except to the extent of our practice has taken action in reliance on such.


You have the right to:

  • request a restriction on certain uses and disclosures of your information as provided by 45 C.F.R. 164.522; however, our practice is not required to agree to a requested restriction;
  • obtain a paper copy of the notice of information practices upon request;
  • inspect and obtain a copy of your health record as provided for in 45 C.F.R.164.524;
  • request that your health record be amended as provided in 45 C.F.R. 164.526;
  • request communications of your health information by alternative means or at alternative locations; and
  • receive an accounting of disclosures made of your health information as provided by 45 C.F.R. 164.528.


You may complain to our Privacy Officer and/or to the Department of Health and Human Services if you believe your privacy right have been violated. You will not be retaliated against for filing a complaint.


Our practice is required by law to:

  • maintain the privacy of protected health information;
  • provide you with this notice of its legal duties and privacy practices with respect to your health information;
  • abide by the terms of this notice;
  • notify you if we are unable to agree to a requested restriction on how your information is used or disclosed; and
  • accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.
  • notify you if a breach in the security of your Protected Health Information (PHI) occurs

Our practice reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you by in-office handouts or via our website.


If you have any questions of complaints, please contact:

Privacy Officer:
La Peer Surgery Center
8920 Wilshire Boulevard, Suite 101
Beverly Hills, CA 90211

3201 Old Glenview Road, Suite 300
Wilmette, IL 60091