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.
Your therapist is committed to maintaining clients’ confidentiality. Your healthcare information will only be released in accordance with federal and state laws and ethics of the counseling profession.
This notice describes the policies related to the use and disclosure of your healthcare information.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION FOR THE PURPOSES OF PROVIDING SERVICES:
Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.
TREATMENT:
Your therapist may need to use of disclose health information about you to provide, manage or coordinate your care or related services, which could include consultants and potential referral sources.
PAYMENT:
Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. Your therapist may bill the person in your family who pays for your insurance.
HEALTHCARE OPERATIONS:
Your therapist may need to use information about you to review their treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.
Other uses or disclosures of your information which does not require your consent:
There are some instances where your therapist may be required to use and disclose information without your consent. For example, but not limited to:
Information you and/or your child or children report about physical or sexual abuse, then by Illinois State Law, your therapist is obligated to report this to the Department of Children and Family Services.
If you provide information that informs your therapist that you are in danger of harming yourself or others.
Information to remind you of/or to reschedule appointments or treatment alternatives.
Information shared with law enforcement if a crime is committed on premises or against staff or as required by law such as a subpoena or court order.
Your Therapist’s Responsibilities
Your therapist required by law to maintain the privacy and security of your protected health information. I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. I must follow the duties and privacy practices described in this notice and give you a copy of it. I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this. I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.
Ask me to correct your medical record. You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications. You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.
Ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or operations. I am not required to agree to your request, and I may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get a list of those with whom I’ve shared information. You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before I take any action.
File a complaint if you feel your rights are violated. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775,or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.