Patient Acknowledgement

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Chicago Gastro LLC is committed to protecting the privacy of your medical information. This Notice tells you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.

We may use or disclose your health information in the following situations:

  • To provide health care services to you, to get reimbursed for those services, and to operate our
    business
  • To assist law enforcement officially as part of an investigation in which you are the victim of a crime,
    abuse or domestic violence
  • To assist public health agencies in the event of a communicable disease or a defective product or
    device (for example, food or medication)
  • To provide you with appointment reminders or information about other services we offer
  • To measure your satisfaction with our services or provide you with information about our efforts to
    raise funds in support of our mission
  • If you otherwise give us permission in the form of a written authorization

Although your heath record is the physical property of Chicago Gastro LLC, the information belongs to you. Your rights include the following:

  • To request a restriction on certain uses and disclosures on how we may use your health information
  • To receive confidential communications about your health care
  • To review and photocopy certain records we maintain containing your health information
  • To request amendments to your health information
  • To know who has accessed your health information and for what purpose
  • To obtain this practice’s current Notice of Privacy Practices upon request

We are 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 by you
  • Abide by the terms of this notice
  • Not disclose your health information without your authorization, except for purposes of treatment,
    payment, or health care operations
  • Accommodate reasonable requests you may have to communicate health information by alternative
    means or at alternative locations

Chicago Gastro LLC reserves the right to change the terms of its Notices of Privacy Practices, and to make new provisions effective for all protected health information that it maintains.