The office of Bloomington Pediatrics, LTD will only release records with the completion of a written request. For their convenience, our office provides patients with a release form they may complete in office or on our website. Requests for records MUST be signed. Unsigned requests cannot be processed.
Requests may be made by E-mail; however, our office must warn the patient/parent that the transmission is unsecure and the individual must accept the risks associated with the transmission. It is preferable that the patient/parent make an electronic request through their patient portal which is secure. The “closing signature” of the E-mail or portal message shall constitute an acceptable signed request.
Records requests will be processed and fulfilled within 30 working days, in keeping with HIPAA and IL state law, though every effort should be made to complete the requests as soon as reasonably possible. If our office cannot complete a request within 30 working days, the law allows a one-time, 30-day extension and our office must inform the individual requesting records of the reason(s) for the delay and the date by which the information will be provided.
Our office may not release records which belong to another physician. We may only release records that were created in our facility by our physicians and staff. Patients/Parents will need to contact the other physician office directly for copies of those records.
In the event records are requested by a patient/parent stating it is for court/legal purposes, they shall be instructed to have a formal request sent by their attorney.
There is NO CHARGE for records sent to another physician office. This applies to patients transferring out of our practice or to records being sent to a specialist. If a patient is transferring out of the practice, we will only send records to their new physician ONCE free of charge. Any additional requests for records to be transferred to another physician will be subject to a charge. There is no limit on the number of specialists to whom records will be released.
Records requested for personal use, that are already stored electronically, will be subject to the flat fee of $6.50 ONLY if the quantity exceeds 12 pages. For 12 pages or less, there is NO CHARGE. This fee applies to patients transferring out of our practice who have not secured another physician and are requesting to carry their records until they establish with a new office.
Records requested by insurance companies and by attorneys, that are already stored electronically, will be subject to a flat fee of $6.50 ONLY if the quantity exceeds 12 pages. For 12 pages or less, there is NO CHARGE.
Records that are still in a paper chart will be subject to a per page fee, according to Illinois state medical record copying fee schedule 735 ILCS 5/8-2001(d).
2021 Fee Schedule
$1.11 per page
$0.74 per page
Pages in excess of 50
$0.37 per page
*The Handling Charge fee does not apply to patient requests. The Handling Charge fee applies ONLY to requests for third party access (attorneys, etc.).
Records that are already stored electronically will be prepared for the requestor in an electronic format, unless otherwise noted in the signed release. Fees remain the same regardless of whether the records are prepared for electronic or paper distribution.
Records that are still in a paper chart will be scanned and distributed in an electronic format unless the requestor notes in the signed release they want a paper copy.
Records will not be released until we receive payment when fees apply. HOWEVER, records MAY NOT be held against payment of an outstanding balance for medical services on the patient’s account. The Billing Department will follow their policy and procedure for transfer balances separately from any medical records fees.
Records may not be faxed or emailed to any entity. It is our office policy to mail records.
Patients/Parents may pick up records in person with a valid photo ID.
In the case of a patient over 18 years of age, who has not completed an age release form allowing a parent access to their medical records, and who also is not living locally to visit the office to complete an age release form; The patient may complete an age release form on our website to grant permission for a parent to pick up records on their behalf.
When records are released in person, it shall be noted in the patient’s account: the name of the person picking up, their relationship to the patient, as well as the type of documentation that was picked up.
All records released from our office shall be recorded in the Logbook and retained for a period of 1 year.
Our office reserves the right to change this policy at any time. This policy will remain in effect from the effective date in the bottom right corner until such changes may be made and a new effective date is established.
Revised to reflect the 2013 HIPAA/Omnibus Final Rule. HIPAA refers to Health Insurance Portability and Accountability Act.
This Notice describes how health information about you may be used and disclosed and how you can get access to this information. This Notice provides you with information to protect the privacy of your confidential healthcare information, hereafter referred to as protected health information (PHI). This Notice also describes the privacy rights you have and how you can exercise those rights. Please review it carefully.
If you have any questions about this Notice, please contact our practice Privacy Officer This Notice is effective as of 7/20/2014
OUR COMMITMENT REGUARDING YOUR PERSONAL HEALTH INFORMATION
Bloomington Pediatrics is committed to maintaining and protecting the confidentiality of our patients’ personal information. This Notice of Privacy Practices applies to Bloomington Pediatrics and health plans covered by the privacy regulation, for example: health benefit plans, dental plans, employee assistance plans (EAPs) and pharmacy benefits programs (collectively, the Plans). The Plans are required by federal and state law to protect the privacy of your individually identifiable PHI and other personal information. We are required to provide you with this Notice about our policies, safeguards and practices. When the Plans use or disclose your PHI, the Plans are bound by the terms of the Notice, or the revised Notice, if applicable.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
We are required by law to:
- Maintain the privacy of protected health information
- Give you this Notice of our legal duties and privacy practices regarding health information about you
- Follow the terms of our Notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following describes the ways we may use or disclose PHI that identifies you (“Health Information”). Except for the purposes described below, we will use and disclose Health information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.
For Treatment. We may use and disclose PHI for your treatment and to provide you with treatment- related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
For Payment. We may use and disclose PHI so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.
For Health Care Operations. We may use and disclose PHI for health care operations purposes. These uses and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the pediatric care you receive is of the highest quality. We may also share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits & Services. We may use and disclose PHI to contact you to remind you that you have an appointment with us. We may also use and disclose PHI to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. When appropriate we may share PHI with a person who is involved in your medical care or payment for your care, such as your family or close friend. We may also notify your family of your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
Research. Under certain circumstances, we may use and disclose PHI for Research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose PHI for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.
As Required by Law. We will disclose PHI when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Business Associates. We may disclose PHI to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or service. For example, we may use another company to perform our billing services on our behalf. All our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation. If you are an organ donor, we may use or disclose PHI to organizations that that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes, or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release PHI as required by military command authorities. We may also release PHI to the appropriate foreign military authority if you are a member of a foreign military.
Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability, report births and deaths, report child abuse or child neglect, report reactions to medications or problems with products, notify people of recalls of products they may be using, a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition, and the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs and compliance with civil rights laws.
Data Breech Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your Health Information.
Lawsuits and Disputes. If you are involved in a lawsuit dispute, we may disclose Health Information in response to a court or administrative order. We may also disclose Health Information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process, (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person, (3) about the victim of a crime even if, under certain, very limited circumstance, we are unable to obtain the person’s agreement, (4) about a death we believe may be the result of criminal conduct, (5) about criminal conduct on our premises, and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners, and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.
Inmates or Individuals in Custody. If you are in inmate of a corrections institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with healthcare, (2) to protect your health and safety, or the health and safety of others, or (3) the safety and security of the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT & OPT OUT
Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health information that directly relates to that person’s involvement in your health care. IF you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement.
Disaster Relief. We may disclose your PHI to disaster relief organizations that seek it to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we can practically do so.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be may only with your written authorization:
- Uses and disclosures of PHI for marketing purposes
- Disclosures that constitute a sale of your PHI
Other uses and disclosures of PHI not covered by this Notice, or the laws that apply to us will be made only with your written authorization. If you give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. However, disclosures that we made in reliance of your authorization before it was revoked will not be affected by the revocation.
You have the following rights regarding Health Information we have about you.
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make a decision about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Bloomington Pediatrics. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request you have the right to have the
denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic
format, known as an electronic medical record or an electronic health record, you have the right to
request that an electronic copy of your record be given to you or transmitted to another individual or
entity. We will make every effort to provide access to your PHI in the format you request, if it is readily
producible in such format. If the Protected Health Information is not readily producible in the format
you request, your record will be provided in either our standard electronic format, or if you do not want
this format, a readable hard copy will be provided. We may charge you a reasonable, cost-based fee for
the labor associated with transmitting the electronic medical record.
Right to Get a Notice of a Breach. You have the right to be notified upon a breach of any of your
Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us
to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request in writing.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we
made of Health Information for purposes other than treatment, payment and health care operations or
for which you provided written authorization. To request an accounting of disclosures, you must make
your request, in writing, to Bloomington Pediatrics.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Health
Information we use or disclose for treatment, payment or health care operations. You also have the
right to request a limit on the Health Information we disclose to someone involved in your care or the
payment for your care, like a family member or friend. For example, you could ask that we not share
information about a particular diagnosis or treatment with your spouse. To request a restriction, you
must make your request, in writing. We are not required to agree to your request unless you are asking
us to restrict the use and disclosure of your Protected Health Information to a health plan for payment
or healthcare operation purposes and such information you wish to restrict pertains solely to a health
care item or service for which you have paid us out-of-pocket" in full. If we agree, we will comply with
your request, unless the information is needed to provide you with emergency treatment.
Out-of-Pocket Payments. If you paid out-of-pocket (or requested we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI, with respect to that item or service, not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request in writing. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice
at our website www.bloomingtonpediatrics.com. To obtain a paper copy of this Notice, ask at the check in window at the front desk or you may request one be sent to you. Requests must be made in writing.
CHANGES TO THIS NOTICE:
We reserve the right to change this Notice and make the new Notice apply to PHI we already have, as well as any information we receive in the future. We will post a copy of our current Notice at our office. The Notice will contain the effective date on the first page, in the top right-hand corner.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.
You may contact our office at:
Bloomington Pediatrics 306 St. Joseph Drive Bloomington, IL 61701
We understand that work and other life circumstances may prevent a parent from attending an appointment with a child under the age of eighteen. This policy is to ensure a balance of patient needs and our medical responsibility for the care of our patients who are becoming young adults.
Children Under 16 Years Old
Patients under the age of sixteen years old MUST be accompanied by a parent/legal guardian/authorized adult when being seen for ill or well visits. A parent or legal guardian may complete our Consent to Treat form to authorize another adult, such as a grandparent, aunt/uncle or babysitter to accompany children under sixteen years old to their office visits when the parent/legal guardian is absolutely unable to accompany them. We will need to see an ID at check in from the accompanying individual. During the exam, the parent/legal guardian/authorized adult must be present in the building, but may choose to step out of the room at the request of the child. (Consent to Treat Under 18 PDF)
Exceptions to this include visits regarding birth control, sexually transmitted diseases, substance abuse, and physical or sexual abuse; when a minor may legally seek confidential treatment or consultation on their own.
Children 16-17 Years Old
Patients between 16-17 years old may be seen without a parent/legal guardian/authorized adult for an ill or well visit. However, the parent/legal guardian must complete a Consent to Treat an Unaccompanied Minor form. (Unaccompanied Minor PDF) If permission from a parent cannot be obtained, the child cannot be seen, unless it is an exception, as mentioned above, or is a life-threatening emergency.
Patients 18 Years and Older
Patients who are 18 years of age and older may be seen without an adult or parental consent and have a right to privacy which is covered by HIPAA laws. This means we cannot release any information to parents or family members without a signed Age Release by the patient. (18-20 Age Release pdf), (21 and Older Age Release form).
All of the aforementioned forms are available on our practice website www.BloomingtonPediatrics.com under the Forms tab. Each form is available to be downloaded in a PDF file to be completed, signed and returned to the office, or may be completed online as a Web Form which will be submitted directly to our office’s HIPAA secure email inbox.
We work hard to accommodate the busy schedules of our patient families and appreciate your cooperation with completing the necessary paperwork to ensure the safety of your child, as well as allow our physicians to provide them the very best care.
We offer a wide range of general pediatric medical services. Our physicians are all board-certified and fellows of the American Academy of Pediatrics. Our experienced team of nurses, technologists and technicians all hold current certifications in their areas of practice. We look forward to serving you!
Follow us to get valuable updates about the practice
306 St. Joseph Dr., Bloomington, IL 61701
Dial 911 or go to the nearest hospital emergency department
- E-mail – non-medical only
- Monday through Friday, 8AM to 5PM
Business office: Open 8AM to 4:30PM
Questions for nurses: Nurses are available by phone throughout the office day
Scheduled appointments: Appointments are generally available from 9AM to 11:30AM and from 1PM to 4:30PM. You may request these by phone and through your child’s patient portal.
Walk-ins: Established pediatric patients with recent onset of minor illnesses may walk in without appointments from 8 to 9AM and from 4 to 5PM to see one of our pediatricians. At other times, such patients are worked in between scheduled patients or are given an appointment later that day.
*Effective March 16, 2020 – due to Covid-19, ALL walk up visits have been temporarily suspended*
- Saturday, 8AM to Noon; Closed Sunday
Business office: Closed
Questions for nurses: Pediatric phone nurses are available to answer questions on Saturday morning
Scheduled appointments: Same day, sick visit appointments are available for pediatric patients with acute minor illnesses
Walk-ins: We cannot accommodate walk-in patients on Saturdays. Only same day, urgent sick visits by appointment
Families receive e-mailed reminders through their child’s patient portal on the day prior to an appointment.
What to Bring to Your Appointment
Please have all relevant medical records sent to our office prior to your first appointment, especially vaccine records. If this is not possible, please bring a copy with you. A list of current medications will be very helpful also. Please bring your insurance card to each visit, as well as your required insurance co-payment.
Prescriptions and Renewals
New prescriptions and refills may be requested by phone during regular office hours Monday through Friday by following the phone prompts and selecting 2 for the refills and forms line. Refills for routine medications may be requested through your child’s patient portal also. Please contact us a day before you would like to pick up your medication. Only emergency prescriptions will be filled after hours. For your protection, refills may not be processed for patients who have fallen behind on their regular appointments.
We refer many patients to other health care providers and facilities. Our referral secretary will be happy to assist you with scheduling of procedures and appointments. We will be sure that the correct paperwork is filed and that necessary records are sent in advance of your appointment.
Insurance and Co-Pays
We participate in most major health insurance plans. We accept Illinois All Kids, Molina and Meridian managed care plans for established families or with physician pre-approval. We file claims with most insurance companies.
If your insurance requires that you make a co-payment for the services we provide, you will need to pay this at the time of your visit. We accept cash, checks and most major credit cards.
Self-pay patients are welcome. If you do not have health insurance, you must pay for your services at the time of your visit.
We will mail you a statement if you have an outstanding balance. Please call our Billing Department if you have concerns about your balance.
We appreciate the trust that you and thousands of other families have placed in us. One of the ways that we honor that trust is by respecting the privacy of all of our patients, past and present. We maintain rigorous physical, electronic and procedural safeguards to be sure that we protect your health information against unauthorized access. You will be given a complete description of our privacy policies at your first visit. You may view these here HIPAA Privacy Notices.