PLEASE READ BELOW AND SIGN. THANK YOU
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact clinic Director.
WHO WILL FOLLOW THIS NOTICE.
This Notice describes Connections Counseling LLC's and Rosecrance Health Network practices and that of:
Any health care professional authorized to enter information into your service record.
All departments and units of Connections Counseling LLC and Rosecrance Health Network.
Any member of a volunteer group we allow to help you while you are a client with Connections Counseling LLC.
All employees, staff and other Connections Counseling LLC personnel at all service sites.
OUR PLEDGE REGARDING HEALTH AND SERVICE INFORMATION:
We understand that health and service information about you is personal. We are committed to protecting health and service information about you. We create a record of the care and services you receive at Connections Counseling LLC. We need this record to provide you with quality service and to comply with certain legal requirements. This notice applies to all of the records of your service generated by Connections Counseling LLC.
This notice will tell you about the ways in which we may use and disclose health and service information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health and service information.
We are required by law to:
Make sure that health and service information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to health and service information about you; and
Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose health and service information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Service Delivery. We may use health and services information about you to provide you with services. We may disclose health and services information about you to other staff members, technicians, students, or other Connections Counseling LLC personnel who are involved in providing services to you at Connections Counseling LLC. For example, a staff member providing family counseling services to you may need to know if you are receiving other services at Connections Counseling LLC in order to make the family counseling services more effective. In addition, the staff member may need to tell the program manager over transportation about you and your services in order to arrange appropriate transportation. Different departments of Connections Counseling LLC also may share health and service information about you in order to coordinate the different things you need, such as prescriptions, assessments, and other services.
For Payments. We may use and disclose health and service information about you so that the services you receive at Connections Counseling LLC may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about family counseling services you received at Connections Counseling LLC so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a service you are going to receive to obtain prior approval or to determine whether your plan will cover the service.
For Health Care Operations. We may use and disclose health and service information about you for Connections Counseling LLC operations. These uses and disclosures are necessary to run Connections Counseling LLC and make sure that all of our clients receive quality services. For example, we may use health and service information to review our services and to evaluate the performance of our staff in caring for you. We may also combine health and service information about many Connections Counseling LLC clients to decide what additional services Connections Counseling LLC should offer, what services are not needed, and whether certain new services are effective. We may also disclose information to other staff members, volunteers, students, and other Connections Counseling LLC personnel for review and learning purposes. We may also combine the health and service information we have with health and service information form other organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from the set of health and service information so others may use it to study services and services delivery without learning who the specific clients are.
Appointment Reminders. We may use, with your consent, and disclose health and service information to contact you as a reminder that you have an appointment for services at Connections Counseling LLC.
Services Alternatives. We may use and disclose health and service information to tell you about or recommend possible service options or alternatives that may be of interest to you.
As Required By Law. We will disclose health and services information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health and service information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
SPECIAL SITUATIONS
Workers' Compensation. We may release health and service information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose health and service information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury or disability;
To report births and deaths;
To report child abuse or neglect;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
To notify 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 and service 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 health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health and service information about you in response to a court or administrative order. We may also disclose health and service information about you 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 and service information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
About criminal conduct at Connections Counseling LLC; and
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
National Security and Intelligence Activities. We may release health and service information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding health and service information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy health and service information that may be used to make decisions about your care. Usually, this includes service and billing records.
To inspect and copy health and service information that may be used to make decisions about you, you must submit your request in writing to the clinical supervisor. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to service information, you may request that the denial be reviewed. Another licensed health care professional chosen by Connections Counseling LLC will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that health and service information we have about you 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 Connections Counseling LLC.
To request an amendment, your request must be made in writing and submitted to the clinical supervisor. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing of does not include a reason . to support the request. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the health and service information kept by or for Connections Counseling LLC;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of health and service information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the clinical supervisor. Your request must state a time period which may not be longer than six years and may not include dates before February 23, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health and service information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health and service information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a counseling episode you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the clinical supervisor. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health and service matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the clinical supervisor. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
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. Evan if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health and service information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at Connections Counseling LLC. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to Connections Counseling LLC for services, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Connections Counseling LLC or with the Secretary of the Department of Health and Human Services. To file a complaint with Connections Counseling LLC, contact Program Director at 608-233-2100. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF HEALTH AND SERVICES INFORMATION.
Other uses and disclosures of health and service information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health and service information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health and service information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Client Consent Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy at any Connections Counseling LLC office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and disclosure of protected health information about your for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.