This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.
Legal Duties
State and Federal laws require that I keep your medical records private. Such laws require that I provide you with this notice informing you of my privacy of information policies, your rights, and my duties. I am required to abide these policies until replaced or revised. I have the right to revise my privacy policies
for all medical records, including records kept before policy changes are made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to me in an evaluation, intake, or counseling session are covered by the law as private information. I respect the privacy of the information you provide me and I abide by ethical and legal requirements of confidentiality and privacy of records.
Use of Information
Information about you may be used by me for diagnosis, treatment planning, treatment, and continuity of care. I may disclose it to health care providers who provide you with treatment with your permission and business associates affiliated with this office for billing.
Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian or personal representative. It is my policy of this not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Public Safety
Health records may be released for the public interest and safety for public health activities, judicial and ad- ministrative proceedings, law enforcement purposes, serious threats to public safety, essential government func- tions, military, and when complying with worker's compensation laws.
Abuse
If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, I may share this information with law enforcement officials to help prevent future
occurrences and capture the perpetrator.
Prenatal Exposure to Controlled Substances
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
In the Event of a Client's Death
In the event of a client's death, the spouse or parents of a deceased client have a right to access theirchild's or spouse's records.
Professional Misconduct
Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional's actions, related records may be released in order to substantiate disciplinary concerns.
Judicial or Administrative Proceedings
Health care professionals are required to release records of clients when a court order has been placed.
Other Provisions
When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the
client's credit report may state the amount owed, the time-frame, and the name of the clinic or collection agency. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.
Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment i.e. psychiatrists prescribing medications. In such cases your permission to talk with the other professional will be requested.
In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify me in writing where I may· reach you by phone and how you would like me to identify myself. For example, you might request that when I phone you at home or
work, I do not say my name or the nature of the call, but rather the mental health professional's first name only. If this information is not provided to me (below), I will adhere to the following procedure when making phone calls: First I will ask to speak to the client (or guardian) without identifying my name.
If the person answering the phone asks for more identifying information I will say that it is a personal call. If! reach an answering machine or voice mail I will follow the same guidelines.
Your Rights
You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. The charge for this service is $ 0.75 per page, plus postage.
You have the right to cancel a release of information by providing me a written notice. If you desire to have your information sent to a location different than my address on file, you must provide this information in writing.
You have the right to restrict which information might be disclosed to others. However, if I do not agree with these restrictions, I are not bound to abide by them.
You have the right to request that information about you be communicated by other means or to another location. This request must be made to me in writing.
You have the right to disagree with the medical records in my files. You may request that this information be changed. Although I might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file.
You have the right to know what information in your record has been provided to whom. If you desire a written copy of this notice you may obtain it by requesting it from me at any time.
Complaints
If you have any complaints or questions regarding these procedures, please contact me directly. I will get back to you in a timely manner. You may also submit a complaint to the U.S. Dept. of Health and Human Services and/or the IL state licensing agency. If you file a complaint I will not retaliate in any way.
I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications.