Notice of Privacy Practices

Neurosciences Ltd. & Norman V. Kohn, MD

Notice of Privacy Practices for Protected Health Information

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.

This practice creates a medical record of your health information, also called “protected health information” or “PHI,” for the purposes of treating you, receiving payment for our work, and complying with certain policies and laws. We are required by law to provide you with this Notice of our legal duties and privacy practices. We are required by federal and state law to maintain the privacy of your PHI. We are also required by law to notify you if you are affected by a breach of your unsecured PHI.

We may use and disclose your PHI as required or authorized by law. For example, we may use or disclose your PHI for the following purposes:


    • To treat you
    • In referring you to another professional or facility for treatment or testing
    • To contact you
    • In communication with your designated representative or guardian
    • To prevent serious injury

Payment: When an outside agency or company is paying for your treatment,

    • Bills and forms as required
    • Treatment plans, when a managed care company is involved
    • To your employer, if you are being seen on the direct request of your employer
    • To a Workers Compensation carrier, if you are seeking compensation through Workers Compensation or the treatment is paid by Workers Compensation
    • To the Social Security Administration, if you apply for or receive social security disability
    • For compliance with audits by government or commercial payers for your care
    • To government agencies, to resolve dispute over payment or care plans

Health Care Operations:

    • For quality improvement or outcome evaluation
    • For contacting you

Public Health:

    • Reporting adverse reactions to medicines

Law Enforcement:

    • In connection with judicial or administrative proceedings, as allowed or required by law.
    • If required by a court order, warrant, subpoena, summons, or similar process.

Illinois law: Illinois law has certain requirements that govern the use or disclosure of your PHI. Your explicit authorization is required for most disclosures about mental health treatment. Illinois law limits disclosure of personal psychotherapy notes.

Your Rights: You have certain rights under federal and state laws relating to your PHI. You have the right to:

    • Request restrictions on certain uses and disclosures of your PHI. We are not required to grant your request. We are required to comply with your request for restrictions on the use or disclosure of your PHI to health plans for payment or operations when the practice has been paid in full by you, the practice has been notified in writing of the request for restriction, and the disclosure is not required by law.
    • Request specific means for receiving confidential communications. We will make good-faith efforts to comply with reasonable requests.
    • Request to inspect your medical and billing record. Certain records may not be inspected. We may charge a reasonable fee for making and delivering copies.
    • Request that your record be amended. We are not required to agree with your request. If your request is denied, we will inform you of the reason for the denial and you will have opportunity to submit a statement for inclusion in the record.
    • Receive an accounting of disclosures that we have made of your PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization.
    • Receive, upon request, a paper copy of this Notice. We have also posted this Notice at our offices.

Complaints: If you feel that your privacy rights have been violated, you may file a complaint with us in writing. We will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of Health and Human Services in Washington, DC if you feel your privacy rights have been violated.

Authorizations: We are required to obtain your written Authorization when we use or disclose your PHI in ways not described in this Notice. You may revoke your Authorization at any time in writing, except to the extent that we have already acted on your Authorization.

We are required to abide with terms of the Notice currently in effect, however, we may change this Notice. If we materially change this Notice, you can get a revised Notice at or at our office. Changes to the Notice are applicable to PHI already in our possession.

EFFECTIVE DATE: November 10, 2014