This notice is a summary of how mental health records and information about you may be used and disclosed and how you can get access to this information. Your rights are established pursuant to HIPAA, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therein. Please review it carefully.
Your Choices–You have some choices in the way that we use and share information.
–We may not disclose any mental health records or information except as provided under HIPAA, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therein.
–We may not tell any third party family and friends about your condition except as provided for in the above identified laws. For example: only pursuant to a valid subpoena, release of information, pursuant to the Abused and Neglected Child Reporting Act, and under certain other circumstances of imminent risk of harm.
Our Uses and Disclosures
We may use and share your information as we:
–Run our organization
–Bill for our services
–Help with public health and safety issues
–Comply with the law
–Work with a medical examiner or funeral director
–Address certain workers’ compensation, law enforcement, and other government requests and are subject to certain conditions
–Respond to lawsuits and legal actions
Your Rights–When it comes to your health information you have certain rights.
–Get an electronic or paper copy of your mental health record. You can ask to see or get an electronic or paper copy of your mental health record and other health information we have about you. Ask us how to do this. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
–Ask us to correct health information about you that you think is incorrect or incomplete. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us 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 us to contact you in a specific way (for example, home or office) or to send mail to a different address. We will say “yes” to all reasonable requests.
–Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we 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 us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
–Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We 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). We’ll provide one account a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
–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. We will provide you with a paper copy promptly.
–Choose someone to act for you. If you have given someone mental health power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
–File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Service 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 http://www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
Your Choices–For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
–Share information with your family, close friends, or others involved in your care
–Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Other Uses and Disclosures
How do we typically use or share your health information?
Subject to HIPAA, the Illinois Mental Health and Development Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therein, we typically use or share your health information in the following ways:
–To treat you
–To run our organization
–To bill for your services
–We can use and share your health information to bill and get payment from health plans or other entities.
–We may contract with business associates to do work directly for us related to your treatment; this may include billing, consultation, legal, and related business practices. In such circumstances, the business associate will be subject to a Business Associates Agreement which obligates any such associate to maintain privacy consistent with the state and federal requirements outlined herein.
How else can we use or share your health information?
We are allowed or required to share your information in other ways–usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html, and the Illinois Mental Health and Developmental Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therein.
Subject to certain exceptions, we can share health information about you for certain situations such as:
–Helping with product recalls
–Reporting adverse reactions to medications
–Reporting suspected abuse, neglect, or domestic violence
–Preventing or reducing a serious threat to anyone’s health or safety
–We are required by law to maintain the privacy and security of your protected health information.
–We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
–We must follow the duties and privacy described in this notice and give you a copy of it.
–We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
–For more information see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
–The Effective date of this notice is January 30, 2014.
–The privacy official (or other privacy contact):
Patty Roosevelt, LCPC, NCC
DARE TO HOPE COUNSELING
101 McCrosky Professional Park
Columbia, IL 62236
–We never market or sell personal information.