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 written authorization.


DEFINITIONS:

"PHI" refers to the information in your health record that could identify you.

"Treatment, Payment, and Health Care Operations"

Treatment 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 physician.
Payment is 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 coverage. 
Health Care Operations are 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.

"Use" applies to activities within the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. 

"Disclosure" applies to activities outside of the office  such as releasing, transferring, or providing access to information about you to other parties.   

"Authorization" is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a legally required form.


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 following circumstances:

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 authorities.

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 actions.

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 the case.

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.


IV. Patient's Rights and Psychologist's Duties

Patient's Rights:

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 request.

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 access process.

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 amendment process.

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 notice electronically.


Psychologist's Duties:

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.


V. Complaints

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.


VI. Effective Date, Restrictions, and Changes to Privacy Policy

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.