PLEASE RETAIN THIS NOTICE FOR YOUR RECORDS
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law and Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I am required 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 of Privacy Practices. I reserve the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.
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 treatment team members. I may disclose PHI to any other consultant only with your 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 coverage for insurance benefits, processing
claims with your insurance company, reviewing services provided to you to determine medical
necessity, or undertaking utilization review activities. If it becomes necessary to use collection
processes due to lack of payment for services, will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care 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, licensing and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing 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 only with your authorization. I may use PHI to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services.
Required by Law: Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule. Without Authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
• Required by Law, such as the mandatory reporting of child abuse or neglect or elder abuse, or mandatory government agency audits or investigations (such as the social work licensing board or the health department)
• Required by Court Order
• 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 or persons reasonably able to prevent or lessen the threat, including the target of the threat.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submityour request in writing to me at 15010 S Ravinia, Suite 15, Orland Park, IL 60462.
• 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 may be used to make decisions about your care. Your right toinspect and copy PHI will be restricted only in those situations where there is compelling evidence that
access would cause serious harm to you. I may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that 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.
• Right to an Accounting of 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 you 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
• Right to Request Confidential Communication. You have the right to request that I communicate with
you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice. You have the right to a copy of this notice.
If you believe I have violated your privacy rights, you have the right to file a complaint in writing with me at 15010 S Ravinia, Suite 15, Orland Park, IL 60462