At The Marriage Clinic (TMC) we are committed to treating and using protected health information responsibly. This notice describes how private health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact the Privacy Officer at the address/phone number listed at the bottom of this notice. All written requests or appeals should be submitted to the Privacy Officer.
Our pledge to you.
At TMC we understand that health information about you is personal and are committed to protecting the privacy of your health information. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by facility staff or those received from other health care providers. The law requires us to:
Keep health information about you private
Give you this notice of our legal duties and privacy practices with respect to your health information
Follow the terms of the notice currently in effect
Who will follow this notice?
Any health care professional authorized to enter information into your service records, all employees, staff, and any other personnel at TMC who may need access to your information must abide by this notice. All subsidiaries, business associates (e.g., a billing service), sites and locations of this agency may share health information with each other for the purpose of treatment, payment for services, or health care operations described in the notice. Except where treatment is involved, however, only the minimum necessary information needed to accomplish the task will be shared.
State law regarding mental health and developmental disabilities records and communications, the practice of counseling and social work, substance abuse matters, and certain other health issues – as well as federal laws about substance abuse matters – may be even more restrictive about disclosure of clients’ health information than the Health Insurance Portability and Accountability Act (HIPAA). When those more restrictive laws apply, the HIPAA law states we must follow the more restrictive state and federal laws.
How we may use and disclose health information about you
The following categories describe different ways that we may use and disclose health information without your specific consent or authorization. Although examples are provided for each category of use or disclosure, not every possible use or disclosure in a category is listed.
For Treatment:We may use health information about you to provide you with treatment or services. Example: In counseling you about a specific problem, a counselor or supervisor may check your record to see what may have been mentioned about that problem during your intake appointment.
For Payment:We may use and disclose health information about you so that the treatment and services you receive from us may be billed and payment may be collected from you, from an insurance company, or from a third party, if you have authorized such billing. Example: We may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment if you are using insurance to pay for services.
For Health Care Operations:We may use and disclose health information about you for health care operations to help assure that you receive high quality care. Example: We may use health information in your records to review and supervise the services you receive and evaluate the performance of our staff in serving you.
Other Uses or Disclosures That Can Be Made Without Consent or Authorization
Because Illinois law is more restrictive than HIPAA, we will disclose what HIPAA calls Protected Health Information without consent or authorization only when doing so is also in accord with Illinois law. Examples of such unusual situations are:
If you communicate to us a specific threat of imminent harm to another individual, or if we believe there is a clear, imminent risk of injury being inflicted against another individual, we may make disclosures that we think are necessary to protect that person from harm.
If we believe that you present an imminent, serious risk of injury to yourself we may make disclosures we consider necessary to protect you from harm.
We may make disclosures necessary to forestall a serious threat to public health or safety.
We will make disclosures in child abuse or neglect situations as mandated by Illinois law.
We may make disclosures to our attorney, if we need to consult him or her about a legal question or matter related to the services we have provided to you.
In certain legal proceedings when we have been specifically ordered to disclose information by a court. However, we will argue in the court to maintain the privacy of the information whenever we believe it is not in your interest for it to be disclosed or it is not truly relevant to the matters before the court.
Whenand if we are reviewed for purposes of funding, accreditation, reimbursement or audit by a State or federal agency or accrediting body, we are allowed to show the minimum information necessary about you to qualified representatives of’ that entity in order for them to verify the accuracy or legitimacy of using that finding to help support services to you, or in order for them to evaluate the agency for accreditation.
If you are under the age of 18, your parent or guardian has the right to certain basic information about your condition and services rendered or needed.
If you are under 12 years of age, your parent or guardian has the right to know most information about services you receive.
Other uses and disclosures allowed or required by law.
Aside from the above, we may contact you to provide appointment reminders and scheduling, or information about treatment alternatives or other services that may be of interest to you.
Uses and Disclosures of Protected Health Information Requiring Your Written Authorization
Other uses and disclosures of health information not covered by this Notice above, or the laws that apply to us, will be made only with your written authorization. If you give us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose the information about you for the reasons covered by your written authorization. Please understand, however, that we will not be able to take back any disclosures we have already made with your authorization; and that we are required to retain our records of the care and services we have provided to you for a reasonable time period.
Your individual Rights Regarding Your Health Information
You may request, in writing, a limit on the health information we use or disclose about you for treatment, payment or healthcare operations, and may request that we limit the health information disclosed about you to someone who is involved in your care or payment for your care, except when specifically authorized by you, when required by law, or in an emergency. In your request, you must state: (i) what information you want to limit; (ii) whether you want to limit our use, disclosure or both; and (iii) to whom you want to limit the information (for example, disclosures only to your spouse). We will consider your request but are not legally required to accept it. We will inform you of our decision on your request.
You have the right to request that health information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you. We will not ask you the reason for your request, and will accommodate all reasonable requests.
You have the right to inspect and copy the health information that may be used to make decisions about services you receive. Usually this includes billing and formal service records, but does not include psychotherapy notes (i.e., the personal notes of your counselor); information compiled for use in certain civil, or administrative action or proceeding; and protected health information to which access is prohibited by law. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at TMC. If you request a copy of the information, we reserve the right to charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health or service information, you may request that the denial be reviewed. Another licensed health care professional chosen by TMC will review you request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at TMC. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if the information was not created by us, is not part of the health information kept at this agency, if it is not part of the information which you would be permitted to inspect and copy, or if we deem the information you seek to amend is accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information pertaining to the appropriate portion of your record.
You have the right to a list of certain instances where we have disclosed health information about you, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after March 21, 2011. You may receive the list in paper or electronic form. The first disclosure list requested in a 12-month period is free; other requests within the same 12-month period will be charged according to our cost of producing the list. We will inform you of the fee before you incur any costs.
You have the right to a paper copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at TMC.
Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at TMC listed below, or with the Secretary of the United States Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
Changes To This Notice
We reserve the right to change our privacy policies and this notice at any time. Changes will apply to health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice, with the effective date below the title.
John Amendt, LMFT, LCSW
346 Taft Avenue, Suite 030
Glen Ellyn, IL 60137