Effective: June 29, 2026
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 pledge regarding your health information
Revival Clinic understands that medical information about you and your health is personal. We are committed to protecting your Protected Health Information ("PHI") and are required by law to do so.
How we may use & disclose your PHI
- Treatment. To provide, coordinate, or manage your medical care, including with referring providers, labs, pharmacies, and specialists.
- Payment. To bill and obtain payment for services from you, an insurer, or another payer.
- Healthcare operations. Quality assessment, provider review, training, accreditation, licensing, and business management.
- Appointment reminders & follow-up. To contact you about appointments, treatment alternatives, or other health-related benefits.
- As required by law. Including public health activities, abuse or neglect reporting, health oversight, judicial proceedings, and law enforcement.
Uses & disclosures requiring your written authorization
Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of PHI require your written authorization. You may revoke an authorization at any time, in writing.
Your rights
- Inspect and copy your medical and billing records.
- Request an amendment if you believe information is incorrect or incomplete.
- Request an accounting of certain disclosures we have made.
- Request restrictions on certain uses and disclosures.
- Request confidential communications by alternative means or at alternative locations.
- Receive a paper copy of this Notice, even if you have agreed to receive it electronically.
- Be notified following a breach of unsecured PHI.
Our responsibilities
We are required by law to maintain the privacy and security of your PHI, provide this Notice, abide by its terms currently in effect, and notify you if a breach occurs that may compromise the privacy or security of your information.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health & Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.
Changes to this Notice
We reserve the right to change this Notice and to make the revised Notice effective for all PHI we maintain. The current Notice will be posted on this page and available at our clinic.
Contact our Privacy Officer
Revival Clinic — Privacy Officer · Lombard, IL · (331) 214-8898 · Contact form