HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Pledge Regarding Your and Your Child’s Health Information:
We understand that health information about your and your child’s health care is personal. We are committed to protecting health information about you and your family. When your child receives assessment and therapy services we will compile personal and health information about your child. Personal health information may be collected at intake or at other times while your child is receiving services. We may also compile information about you or your family (such as information about pregnancy and family medical history). We need this record to provide you with quality care and to comply with certain legal requirements.
Your clinician is required by law to maintain the privacy of your and your child’s health information (also referred to as “Protected Health Information” or “PHI”) and to inform you of its duties and privacy practices. This Notice describes some of the ways in which we may use or disclose your or your child’s personal health information, and the rights you have concerning your or your child’s health information.
Health Information Includes and Relates to:
- your or your child’s past, present, and future physical, medical or mental health conditions;
- your past, present, or future payment for the care or services your child received; and
- care and services provided to your child.
Handling of Protected Health Information
- Storage: all data obtained is kept in individual patient folders, stored in a locked file cabinet.
- Collection: collection of data is confidential, and is kept within the patient folder, as noted above.
- Fax Transmittals: all fax transmissions are sent on a confidential line, with a cover sheet stating confidential nature of material being transmitted.
- Destruction: per the APA Record Keeping Guidelines, all data will be maintained for three years after the minor reaches the age of majority, at which time the material is destroyed in a secure and confidential manner.
1.) Permissible Uses and Disclosures of Personal Health Information Without Your Written Authorization:
In certain situations, which we describe in Section 2 below, we must obtain your written authorization in order to use and/or disclose your or your child’s Private Health Information. However, we do not need any type of authorization from you for the following uses and disclosures:
Treatment: We may use and disclose your child’s PHI to provide treatment and other services to him/her (i.e., to diagnose and treat injury or illness). In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose your or your child’s PHI to other providers, including consulting clinicians and physicians involved in your child’s treatment (i.e., sharing treatment plan with his/her occupational therapist, service coordinator).
Payment: We may disclose your or your child’s health information for the purposes of payment for services we provide for your child. For example, we may use your child’s PHI for disclosures to claim and obtain payment from Medicaid, your health insurer, HMO, Early Intervention or other company or program that arranges or pays the cost of some or all of your child’s health care (i.e., “Your Payor”) to verify that Your Payor will pay for health care.
Health Care Operations: We may use or disclose your or your child’s health information to conduct health care operations. For example, we may disclose your child’s health information for quality assessment and improvement activities, reviewing the quality and competence of the clinicians providing your family services or for health care fraud and abuse detection or compliance.
When Required by Law: We may disclose your or your child’s health information as required by federal, state or local laws. For example, we may disclose information pursuant to a Federal Grand Jury subpoena.
Government Benefit Programs: We may use or disclose your or your child’s health information as needed for the administration of a government benefit program such as Medicaid.
Federal Oversight and Monitoring: We may disclose your or your child’s health information to an office or agency of the federal government in connection with the federal government’s oversight or monitoring activities. For example, we may disclose information to the Office of Special Education Programs in connection with periodic program audits. In most cases, the information disclosed for this purpose will not permit the individual to be identified.
In an Emergency: We may disclose your or your child’s health information to medical or law enforcement personnel if the information is needed to prevent immediate harm to you or your child. For example, if we believe you are or your child is a victim of abuse, neglect or domestic violence, we may disclose your PHI to the Illinois Department of Children and Family Services (DCFS), the Illinois Department of Human Services (DHS) or other governmental authority, including social service or protective services agency, authorized by law to receive such reports of abuse, neglect or domestic violence.
2.) Uses and Disclosures Requiring Your Written Authorization:
Other uses and disclosures of health information not covered by this notice or the laws that apply to assessment or therapy services will be made only with your written authorization. If you provide us with permission to use or disclose your or your child’s health information, you may revoke that authorization in writing at any time. Should you revoke the authorization, we will no longer use or disclose your or your child’s information for any reasons that require your written authorization. NOTE: The Goldman Center may not take back any disclosures made prior to your processing your revocation request. Federal and Illinois law requires special privacy protections for certain highly confidential information about your and your child’s health including PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; (9) is about sexual content. In order for us to disclose your or your child’s Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.
Minimum Necessary Requirements
The use, disclosure of and requesting of PHI will only be used to complete the task for which information is being requested. Only the minimum necessary information requested will be disclosed.
Your Rights Regarding Health Information
Right to Inspect and Copy: You have the right to inspect and receive a copy of the health information that the Goldman Center has about you or your child in most situations. This includes medical and billing records. You must submit your request in writing to the Goldman Center , and include a time period for which you wish to review your records. Please note that you may be charged a reasonable fee, unless such a fee would prevent you from exercising this right.
Right to Request Amendment: You have a right to ask your clinician to amend the health information it has collected or maintains about you or your child if you feel it is incorrect or incomplete. If your request is approved, your request and the amendment will become part of your permanent record. You must submit your request in writing to the Goldman Center. You must state the reason you are requesting an amendment.
Right to a List of Types and Locations: You have a right to request a list of the types and locations of health information about you or your child collected, used or maintained by the Goldman Center.
Right to Receive an Accounting of Disclosures: You have a right to request a list of each time your clinician has disclosed personal health information about you, for reasons other than treatment, payment or health care operations, or certain other reasons as provided by law. You must submit your request in writing to the Goldman Center . Your request must state a time period that may not be longer than three years after the minor reaches the age of majority. Please note that you may be charged a reasonable fee, unless such a fee would prevent you from exercising this right.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information that we use or disclose about you or your child for treatment, payment and health care operations. You must submit your request in writing to the Goldman Center , and indicate what information you want limited and to whom the limits apply. NOTE: The Goldman Center is not required to agree to your request.
Right To Request and Receive Confidential Communication: You have a right to request that your clinician communicate with you in confidence about your or your child’s personal health information in a different means or at a different location. For example, you may request that we contact you with confidential information only at work or by mail, or communicate with you in your own language if you are non-English or limited-English speaking.
Right to Receive Additional Copies of this Notice: You have a right to receive additional copies of this Notice upon request. To request additional copies, please contact your child’s clinician.
Right to File a Complaint: If you believe your privacy rights have been violated by your clinician, you have the right to complain directly to the Goldman Center , or the U.S. Department of Health and Human Services.
EFFECTIVE DATE AND DURATION OF THIS NOTICE:
This notice is effective on or before August 1, 2009. The Goldman Center is required to follow the terms of this Notice until the Notice is revised. The Goldman Center reserves the right to revise or change the contents of this notice at any time. If it does so, the new Notice will be available at your clinician’s office location within 30 days after the effective date of the change. The new Notice will state “Revised” and will include the date the change became effective.
PRIVACY OFFICER/COMPLAINTS:
The clients and/or their guardians of the Goldman Center , have the right to voice their complaints. Complaints should be made in writing to the Goldman Center, 230 W. Division St #908, Chicago, IL 60610. Upon receipt of a complaint, an action plan to resolve the problem will be implemented. Should a complaint remain unresolved, please direct complaints to:
Region V, Office for Civil Rights
U.S. Dept. of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
OR
Department of Health and Human Services
Office of Civil Rights Hubert H. Humphrey Bldg.
200 Independence Avenue,
S.W. Room 509F HHH Building
Washington, DC 20201
HIPAA NOTICE OF PRIVACY PRACTICES RECEIPT ACKNOWLEDGMENT
EFFECTIVE DATE: AUGUST 1, 2009
I acknowledge that I have been provided this Notice of Privacy Practices:
- It tells me how the Goldman Center of Chicago will use my health information for the purposes of my child’s treatment and payment for treatment.
- The Notice also explains in more detail how my child’s health information may be used and shared for reasons other than treatment, payment, and health care operations.
- My health information may also be used as required/permitted by law.