This notices describes how medical information about you may be used and disclosed and how you can have access to this information. Please review carefully and sign below.
Your health record contains personal information about you and your health. The information about you may identify you and relates to your past or future physical or mental health and related health care services is referred to as Protected Health Information or 'PHI'. This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act or 'HIPAA', regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may access and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice. I reserve the right to change the terms of my Notice at any time. Any new Notices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice either by mail or electronically upon your request.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other team members. I may disclose PHI to any other consultant only with your written authorization.
For payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or benefits of health insurance coverage, processing claims with your health insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processed due to non payment I will only disclose the minimum amount of PHI necessary for purposes of collection.
For healthcare operations: I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, conducting or arranging for other business activities (e.g.billing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. FOr training or teaching purposes PHI will be disclosed with authorization only.
Required by law: Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to teh Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.
The following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit me to disclose information about you without authorization only in a limited number of situations.
As a social worker licensed in Illinois and as a member of the National Association of Social Workers it is my practice to adhere to more stringent privacy requirementsfor disclosures without an authorization. The following language addresses these categories to the extent consistent with HIPAA.
Child Abuse or Neglect: I may disclose your PHI to a state or local agency that is authorized by laow to receive reports of child abuse or neglect.
Judicial or Administrative Proceedings: I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order, or similar process.
Deceased Clients: I may disclose PHI regarding deceased clients as required by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based upon your prior consent. A release of information regarding deceased clients may be limited to an executor or adminstrator of a deceased person's estate or identified next-of-kin. PHI of persons that have been deceased over fifty years is not protected under HIPAA.
Medical Emergencies: I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a coping of this notice as soon as reasonably practicable after the resolution of the emergency.
Family Involvement in Care: I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
Health Oversight: If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to you (such as third party payors) and peer review organizations providing utilization review and quality control.
Law Enforcement: I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with report a crime of emergency, or in connection with a crime on the premises.
Specialized Governmental Functions: I may review requests from U.S. Military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and the the Department of State for medical suitability determinations, and disclose your PHI based upon your written consent, mandatory disclosure laws adn the need to prevent serious harm.
Public Health: If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purposes of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a governmental agency that is collaborating with the public health authority.
Public Safety: If required, I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person reasonably able to prevent or lessen the threat, including the target of the threat.
Research: PHI may only be disclosed after a special approval process or with your authorization.
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: most uses of psychotherapy notes which are separated from the rest of your medical record; most uses for marketing purposes, including subsidized treatment communications; disclosures that constitute a sale of PHI; and other usese not described in the Notice.
YOUR RIGHTS REGARDING YOUR PHI
You have the following right regarding PHI that I maintain about you. To exercise any of these rights please submit your request in writing to 4811 Emerson Ave. Suite 101 Palatine, Il 60067.
Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a 'designated record set'. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and receive a copy of PHI will be restricted only in those situations wher there is compelling evidence that access would cause serious harm to you of if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable, cost based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request your PHI be provided to another person.
Right to Amend: If you feel the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy.
Right of Accounting Disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if your request more than one accounting in any 12 month period.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care related operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, I am required to honor your request for a restriction.
Right to Request Confidential Communication: You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as condition for accommodating your request. I will not ask you for an explanation of why you are making the request.
Breach Notification: If there is a breachof unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
If you believe we have violated your privacy rights, you have the right to file a complaint in writingwith the Secretary of Health and Human Services at 200 Independence Avenue SW Washington DC 20201 or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.
Effective date of this notice is October 15, 2021.