KRAMER ENTERPRISES DME DIVISION
Notice of Privacy Practices Form

The Notice of Privacy Practice provides detailed information about how Cardinal Sleep Centers may use and disclose my confidential information.

I understand that Cardinal Sleep Centers has reserved a right to change their privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available upon request.

I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so. I also understand that I will not be able to revoke this consent in cases where Cardinal Sleep Centers has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the Cardinal Sleep Centers.

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.

Cardinal Sleep Centers-DME Division acts to maintain the privacy of protected health information and provide individuals with notice of the practice’s legal duties and privacy practices with respect to protected health information as described in this Notice and abide by the terms of the Notice currently in effect.

Provision of Notice: Cardinal Sleep Centers provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided no later than the date of the first treatment to the patient after April 13, 2003.

Cardinal Sleep Centers makes its Notice available to any member of the public to enable prospective patients to evaluate the practice’s privacy practices when making his or her decision regarding whether to seek treatment from the practice. The practice provides its Notice via e-mail to any patient or other individual who so requests the Notice.

Documentation of Provision of Notice: When a direct treatment patient receives the Notice from Cardinal Sleep Centers, Cardinal Sleep Centers asks the patient to sign its “Receipt of Notice of Privacy Practices” form. The form is filed with the patient’s medical record. If the patient refuses to sign the form, it is noted in the medical record that the patient was given the Notice and refused to sign the form.

Effective Date and Changes to Notice: This Notice is effective April 14, 2003. Cardinal Sleep Centers reserves the right to revise this Notice whenever there is a material change to the uses or disclosures, the individual’s rights, the covered entity’s legal duties, or other privacy practices stated in the Notice. Except when required by law, a material change to any term of the Notice will not be implemented prior to the effective date of the notice in which such material change is reflected.

If the Notice is revised, Cardinal Sleep Centers makes the revised Notice available upon request beginning on the revision’s effective date. The revised notice is posted in the practice’s reception area and made available to all patients, including those who have received a previous Notice. Upon receipt of a revised Notice, a patient is asked to acknowledge receipt of the Notice.

In addition, Cardinal Sleep Centers will contact the individual with appointment reminders or information about treatment alternatives or other heath-related benefits and services that may be of interest to the individual.

Complaints: Cardinal Sleep Centers allows all patients and their agents to file complaints with the practice and with the Secretary of the federal Department of Health and Human Services (DHHS). A patient or his or her agent may file a complaint with the practice whenever he or she believes that the practice has violated their rights.

Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of the practice’s privacy officer at the practice’s address. The practice investigates each complaint and may: at its discretion, reply to the patient or the patient’s agent.

Complaints to the Secretary of the Department of Health and Human Services must be in writing, must name the practice, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to: Cardinal Sleep Centers Privacy Officer 3077 W. Jefferson Street, Suite 214, Joliet IL 60435.