HIPAA: Notice Of Privacy Practice
This notice, adapted from the U.S. Department of Health and Human Services, describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Information. Your Rights. My Responsibilities.
Your Rights
When it comes to your Protected Health Information (PHI), you have certain rights. This section explains your basic rights and some of my responsibilities to help you.
Get A Paper Copy Of Your Clinical Record
- You can ask to see or get an electronic or paper copy of your clinical record and other health information I have about you. Ask me how to do this.
- I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.
Ask Me To Correct Your Clinical Record
- You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.
- I may say “no” to your request, but I’ll tell you why in writing within 60 days.
Request Confidential Communications
- You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- I will say “yes” to all reasonable requests.
Ask Me To Limit What I Use Or Share
- You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and I 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 me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get A List Of Those With Whom I’ve Shared Information
- You can ask for a list (accounting) of the times I have shared your health information for six years prior to the date you ask, who I shared it with, and why.
- I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make).
- I’ll provide one accounting 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 Notice Of Privacy Practice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose Someone To Act For You
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- I will make sure the person has this authority and can act for you before I take any action.
Right To Receive A Notice Of A Breach
- You have the right to be notified in writing following a breach of your health information that was not secured in accordance with security standards as required by law.
File A Complaint If You Feel Your Rights Are Violated
- You can complain if you feel I have violated your rights by contacting Charles Berry, Psy.D. at (773) 643-8088.
- You can file a complaint with the U.S. Department of Health and Human Services 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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
- I will not retaliate against you for filing a complaint.
Your Choices
For Certain Health Information, You Can Tell Me Your Choices About What I Share.
If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions. If you are not able to tell us your preference, we may share your information if we believe it is in your best interest.
In These Cases, You Have Both The Right And Choice To Tell Me To:
- Share information with your family, close friends, your other health care providers, or others involved in your care
- Share information in a disaster relief situation
- If your health information is accessible through the HIE, you may provide a written request to opt-out of further disclosure by the HIE to third parties, except to the extent permitted by law (See www.hie.illinois.gov for information on opting-out)
Written Authorization
Any other uses and disclosures of your health information not described in this Notice will be made only with your authorization. The following are disclosures requiring your written authorization include:
- Subject to exceptions, uses and disclosures of your health information for marketing purposes. However, I will ask you if you would like me to contact you with other services or products the Guidepost Center provides. In order to do this, you have to sign a written consent.
- Disclosures that constitute a sale of your health information.
- Most uses and disclosures of psychotherapy notes.
My Uses And Disclosures
How Do I Typically Use Or Share Your Health Information?
I typically use or share your health information in the following ways.
Run My Organization
I can use and share your health information to run my practice, improve your care, and contact you when necessary.
Example: I use health information about you to manage your treatment and services.
Bill For Your Services
I can use and share your health information, as needed, to bill and get payment from health plans or other entities.
Example: I give information about you to your health insurance plan so it will pay for your services.
In Treating You
I can use your health information and share it with other professionals that are treating you (if you provide me with written authorization to do so.)
Business Associates
I may disclose your health information to our third-party business associates (for example, a billing company or accounting firm) that performs activities or services on our behalf. Business associates must agree in writing to protect the confidentiality of your information.
Example: We may use or disclose your health information to a business associate that we use to provide reminders to you of an upcoming appointment.
Special Situations
How else can I use or share your health information?
I am 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. I have to meet many conditions in the law before I can share your information for these purposes. The following are other uses and disclosures we make of your health information without your authorization, consent or opportunity to object. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help With Public Health And Safety Issues
I may use or disclose your health information in certain situations, such as in order to prevent/report communicable diseases, helping with product recalls, reporting adverse reactions to medications, to prevent or reduce a serious threat to anyone’s health or safety, and for work place surveillance or work related illness and injury.
Comply With The Law
I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I’m complying with federal privacy law.
Health Oversight Activities
I may use and disclose your health information to state agencies and federal government authorities, or to a health oversight agency, for activities authorized by law such as audits, administration or criminal investigations, inspections, licensure, accreditation or disciplinary action and monitoring compliance with the law, including in order to determine your eligibility for public benefit programs and to coordinate delivery of those programs. The Illinois Mental Health and Developmental Disabilities Confidentiality Act allows for the un-consented disclosure of your health information to a health information exchange (HIE), which oversees the electronic exchange of health information, for HIE purposes. See 740 ILCS 110/9.5.
Coroner/Medical Examiner, Law Enforcement, And Other Government Requests
This includes certain narrowly defined disclosures to law enforcement agencies, to health oversight agencies, to a coroner or medical examiner, for public health purposes and for special government functions, such as military, national security and presidential protective services. The likelihood that I will be required to make any of these disclosures arelow, but I’m legally required to inform you about the possibility.
Workers’ Compensation
I may disclose your health information as authorized to comply with worker’s compensation claims.
Respond To Lawsuits And Legal Actions
I can share health information about you in response to a court or administrative order, or in response to a subpoena.
Abuse and Neglect Reporting
I may disclose Health Information to report child abuse or neglect, or elder abuse or neglect.
Avert Suicide Or Violence/Homicide
I may use and disclose Health Information necessary to prevent serious threat to your health and safety or to the health and safety of the public or another person.
Respond To Lawsuits And Legal Actions
I can share health information about you in response to a valid court or administrative order, or in response to a subpoena, to the extent that such disclosure is authorized and permissible under the Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/1 et seq.
Please note: In Illinois, state confidentiality law is much stricter than HIPAA when it comes to mental health records (as is the Code of Ethics of Psychologists of the American Psychological Association).
Other Important Information
Changes To The Terms Of This Notice
I 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 web site. The effective date of this Notice of Privacy Practices is September 23, 2013.
Other Laws And Regulations
Charles Berry further complies with the following state and federal laws and regulations related to the disclosure of your protected health information:
Mental Health Records Disclosure:
I comply with the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/1 et seq.
Alcohol/Substance Abuse Records Disclosure:
We comply with the federal Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 et seq. If any requested records contain information regarding alcohol or drug abuse treatment, these records are protected by Federal confidentiality rules, and such information is prohibited from further disclosure without express permission by written consent of the person to whom it pertains or as otherwise permitted by Federal Rules. A general authorization for the use or release of medical or other information is insufficient for this purpose. Federal rules restrict use of the information for criminal investigation or prosecution of any alcohol or drug abuse patient. See 42 U.S.C. § 290dd-3 and § 290ee-3; 42 C.F.R. Part 2 et seq.; and 20 ILCS 301 et seq.
My Responsibility
We are required by law to maintain the privacy and security of your protected health information. We will not use or disclose your health information other than as described here unless you provide written authorization. You may revoke your authorization at any time, in writing, but only as to future uses or disclosures and only where we have not already acted in reliance on your authorization.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
This Notice of Privacy Practices applies to Charles Berry: Guidepost Center for Personal Development in Chicago, Illinois. Please contact Charles Berry with any questions.
My Contact Information:
1525 E. 53rd Street, Suite 503, Chicago, IL 60615
Privacy Officer: Charles Berry, Psy.D.
Telephone/Fax: 773-643-8088
Email: berry@guidepostcenter.com