I. Uses and
Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your Protected Health Information (PHI), for
treatment, payment, and health care operations purposes with your
to the information in your health record that could identify you.
"Treatment, Payment, and Health Care
is the provision, coordination, or management of your health care and
other services related to your health care. An example of treatment is
my consulting with another health care provider, such as a family
obtaining reimbursement for your healthcare. Examples of payment are
when we disclose your PHI to your health insurer to obtain
reimbursement for your health care or to determine eligibility or
activities that relate to the performance and operation of my practice.
Examples of health care operations are quality assessment and
improvement activities, business-related matters such as audits and
administrative services, and case management and care coordination.
applies to activities within the office such as sharing, employing,
applying, utilizing, examining, and analyzing information that
applies to activities outside of the office such as
transferring, or providing access to information about you to other
is your written permission to disclose confidential mental health
information. All authorizations to disclose must be on a legally
II. Other Uses
and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment,
or health care operations when your appropriate authorization is
obtained. In those instances when we are asked for information for
purposes outside of treatment, payment, or health care operations, we
will obtain an authorization from you before releasing the information.
You may revoke such authorizations at any time, provided the revocation
is in writing. You may not revoke an authorization to the extent that
(1) We have relied on that authorization; or (2) If the authorization
was obtained as a condition of obtaining insurance coverage, the law
provides the insurer the right to contest the claim under the policy.
III. Uses and
Disclosures without Authorization
I may use or disclose PHI without your consent or authorization in the
Child Abuse - If I have reasonable cause to believe a child known to me
in my professional capacity may be an abused child or a neglected
child, I must report this belief to the appropriate authorities.
Adult and Domestic Abuse - If I have reason to believe that an
individual (who is protected by state law) has been abused, neglected,
or financially exploited, I must report this belief to the appropriate
Health Oversight Activities - I may disclose protected health
information regarding you to a health oversight agency for oversight
activities authorized by law, including licensure or disciplinary
Judicial and Administrative Proceedings - If you are involved in a
court proceeding and a request is made for information by any party
about your evaluation, diagnosis and treatment and the records thereof,
such information is privileged under state law, and I must not release
such information without a court order. I can release the information
directly to you on your request. Information about all other
psychological services is also privileged and cannot be released
without your authorization or a court order. The privilege does not
apply when you are being evaluated for a third party or where the
evaluation is court ordered. You must be informed in advance if this is
Serious Threat to Health or Safety - If you communicate a specific
threat of imminent harm against another individual or if I believe that
there is clear, imminent risk of physical or mental injury being
inflicted against another individual, I must make disclosures that I
believe are necessary to protect that individual from harm. If I
believe that you present an imminent, serious risk of physical or
mental injury or death to yourself, I must make disclosures I consider
necessary to protect you from harm.
Worker's Compensation - I may disclose protected health information
regarding you as authorized by and to the extent necessary to comply
with laws relating to worker's compensation or other similar programs,
established by law, that provide benefits for work-related injuries or
illness without regard to fault.
Rights and Psychologist's Duties
Right to Request Restrictions - You have the right to request
restrictions on certain uses and disclosures of protected health
information. However, I am not required to agree to a restriction you
Right to Receive Confidential Communications by Alternative Means and
at Alternative Locations - You have the right to request and receive
confidential communications of PHI by alternative means and at
alternative locations. (For example, you may not want a family member
to know that you are seeing me. On your request, I will send your bills
to another address.)
Right to Inspect and Copy - You have the right to inspect and/or obtain
a copy of PHI in my mental health and billing records used to make
decisions about you for as long as the PHI is maintained in the record.
On your request, I will discuss with you the details of the request for
Right to Amend - You have the right to request an amendment of PHI for
as long as the PHI is maintained in the record. I may deny your
request. On your request, I will discuss with you the details of the
Right to an Accounting - You generally have the right to receive an
accounting of disclosures of PHI. On your request, I will discuss with
you the details of the accounting process.
Right to a Paper Copy - You have the right to obtain a paper copy of
the notice from me upon request, even if you have agreed to receive the
To maintain the privacy of PHI and to provide a notice of my legal
duties and privacy practices with respect to PHI.
To reserve the right to change the privacy policies and practices
described in this notice. Unless you are notified of such changes we
are required to abide by the terms currently in effect.
In the event of revisions of policies and procedures, you will be
notified in person or by mail.
If you are concerned that we have violated your privacy rights, or you
disagree with a decision we made about access to your records, please
contact us at (312) 616-0006. You may also contact the Illinois
Department of Insurance Consumer Assistance Hotline at (866) 445-5364,
or their Consumer Services Section at (312) 814-2427.
You may also send a written complaint to the Secretary of the U.S.
Department of Health and Human Services. The contacts listed above can
provide you with the appropriate address upon request.
This notice went into effect on April 14, 2003. We reserve the right
to change the terms of this notice and to make the new notice
provisions effective for all PHIs maintained. We will provide you with
a written revised notice.
312 . 616 .