THIS NOTICE DESCRIBES HOW MEDICAL AND PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are committed to maintaining the privacy of your protected health information (PHI). PHI includes private information such as:
- Birthdates and dates of service (admission, discharge, etc.)
- Phone numbers
- E-mail addresses
- Social security numbers
- Health insurance plan information
This information may be utilized in the following instances:
Treatment: Personal information may be used to determine diagnostic and therapy services. This information may also be shared with other professionals involved in your care (i.e., service coordinators, other treating therapists, physicians or other specialists).
Payment: We may use your personal information to bill for services and obtain payment from health plans or other entities if required.
Health Care Operations: We may use your personal information to operate our practice, improve your care, and contact you when necessary. Patient authorization may not be sought in the case of preventing serious threat to health or safety, abuse or neglect, domestic violence, legal processes (i.e., court or administrative order, subpoena), law enforcement purposes (i.e., compliance of privacy laws), or workers’ compensation claims.
Appointment Reminders: We may use your personal information to contact you and remind you of an appointment.
Health Related Benefits and Services: We may use and disclose medical information to inform you about treatment options and health related benefits or services that may be of interest to you.
Sharing Your Information
You may request how we share your information. With your consent, we may share your personal information with other individuals involved in your care (i.e., caretaker, babysitter, family members, or others you have identified) or individuals having the right to act on your behalf (i.e., DCFS representatives or foster parents).
We will require your written permission to utilize your personal information for reasons not stated in this notice. If you request your permission to be withdrawn, your personal information will no longer be shared. We will not be able to retract disclosures previously made with your authorization.
Copies of medical records: You may request a copy of your medical records or treatment documents. There may be a reasonable, cost-based fee. All requests will be processed within a 30 day time period.
Correction to medical records: You may ask for a correction to be made to your medical records if you find something to be inaccurate or incomplete. We may decline your request if information is subject to law or reason for request is invalid.
Confidential communications: You may request that we contact you in a specific manner (i.e. phone vs. mail, office phone vs. home phone, etc.) or to send mail to a different address. We will comply with all reasonable requests.
Requesting restrictions: You may request a restriction on the use or sharing of certain health information for treatment, payment, or health care operations. However, we may decline your request if it affects your care.
List of disclosures: You may request a list (accounting) of the times your health information has been shared. Information regarding who we shared it with and why may be obtained as long as the date of request does not exceed six years. There may be a reasonable cost-based fee.
Get a copy of this privacy notice: You may request a copy of this notice at any time.
File a complaint: If you feel that you or your dependents rights have been violated at any time you have the right to file a complaint with us by contacting Sarah Chlebek, the assigned privacy officer. You may also contact 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/ . You will not be penalized in any way for filing a complaint. Please adhere by the following when filing a complaint:
- A complaint must be filed in writing, either on paper or electronically.
- A complaint must name the person that is the subject of the complaint and describe the acts or omissions believed to be in violation.
- All complaints must be filed within 180 days of a reported event.
- We are committed to maintaining the privacy and security of your PHI.
- We will notify you if the privacy of your information is compromised.
- We will follow the privacy practices stated in this notice and provide you a copy of it.
- We have the right to make changes to this notice. If changes occur we will provide you with a new copy.
- We regulate access to your personal information and maintain appropriate security measures to protect it.
- We will dispose of all personal information in an appropriate and secure manner.
- We will retain your personal information for up to seven years following termination of services.
HIPAA Notice of Privacy Practices
I have received, read, and understood the notices of Privacy Practices.
Patient Name: _______________________________
Patient / Parent / Guardian Signature: _______________________________________