Notice of Health Care Provider's 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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Integra Counseling Services, Inc. ("Provider") may use your health information; that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Provider has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment. Provider may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. The Provider also may disclose your health care information to individuals outside of the Provider involved in your care including family members, pharmacists, suppliers of medical equipment, or other health care professionals.
To Obtain Payment. Provider may include your health information in invoices to collect payment from third parties for the care you may receive from Provider. For example, Provider may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Provider. The Provider also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you.
To Conduct Health Care Operations. Provider may use and disclose health information for its own operations in order to facilitate the function of Provider and as necessary to provide quality care to all of Provider's patients. Health care operations include activities such as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol development, case management, and care coordination.
- Contacting health care providers and clients with information about treatment alternatives and other related functions that do not include treatment.
- Professional review and performance evaluation.
- Training programs including those in which students, trainees, or practitioners in health care learn under supervision.
- Training of nonhealth care professionals.
- Accreditation, certification, licensing, or credentialing activities.
- Review and auditing, including compliance reviews, medical reviews, legal services, and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of Provider.
For example, Provider may use your health information to evaluate its staff performance, combine your health information with other Provider clients in evaluating how to more effectively serve all of Provider's clients, disclose your health information to Provider staff and contracted personnel for training purposes, or use your health information to contact you as a reminder regarding a visit to you.
For Appointment Reminders. Provider may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care with Provider.
For Treatment Alternatives. Provider may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
When Legally Required. Provider will disclose your health information when it is required to do so by any Federal, State, or local law.
When There Are Risks to Public Health. Provider may disclose your health information for the following public activities and purposes:
- To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
To Report Abuse, Neglect, Or Domestic Violence. Provider is allowed to notify government authorities if Provider believes a client is the victim of abuse, neglect, or domestic violence. Provider will make this disclosure only when specifically required or authorized by law or when the client agrees to the disclosure.
To Conduct Health Oversight Activities. Provider may disclose your health information to a health oversight agency for activities including: audits; civil, administrative or criminal investigations; inspections; licensure, or disciplinary action. Provider, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits.
In Connection With Judicial And Administrative Proceedings. As permitted or required by state law, Provider may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request, or other lawful process. Reasonable efforts will be made to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by State law, Provider may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
To Coroners And Medical Examiners. Provider may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors. Provider may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Provider may disclose your health information prior to, and in reasonable anticipation of, your death.
For Organ, Eye Or Tissue Donation. Provider may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.
For Research Purposes. Provider may, under very select circumstances, use your health information for research. Before Provider discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.
In the Event of A Serious Threat To Health Or Safety. Provider may, consistent with applicable law and ethical standards of conduct, disclose your health information if Provider, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize Provider to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker's Compensation. Provider may release your health information for worker's compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, Provider will not disclose your health information other than with your written authorization. If you or your representative authorizes Provider to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Provider maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Provider's disclosure of your health information to someone who is involved in your care or the payment of your care. However, Provider is not required to agree to your request. If you wish to make a request for restrictions, please contact Dr. Jill Zimmerman, President, at 715-386-9011.
Right to Receive Confidential Communications. You have the right to request that Provider communicate with you in a certain way. For example, you may ask that Provider only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact your therapist. Provider will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to your therapist. If you request a copy of your health information, Provider may charge a reasonable fee for copying and assembling costs associated with your request.
Right to Amend Your Health Information. You or your representative have the right to request that Provider amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Provider. A request for an amendment of records must be made in writing to Dr. Jill Zimmerman, President, 206 Walnut Street, Hudson, WI 54016. Provider may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Provider, if the records you are requesting are not part of Provider's records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Provider, the records containing your health information are accurate and complete.
Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Provider for certain purposes, which may include disclosures authorized by law and disclosures made for research. The request for an accounting must be made in writing to Dr. Jill Zimmerman, 206 Walnut Street, Hudson, WI 54016. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Provider will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact your therapist.
DUTIES OF PROVIDER
Provider is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. Provider is required to abide by the terms of this Notice as may be amended from time to time. Provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Provider makes a material change to this Notice, Provider will provide a copy of the revised Notice to you or your appointed representative. You or your representative has the right to express complaints to Provider and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to Provider should be made in writing to Dr. Jill Zimmerman, President, 206 Walnut Street, Hudson, WI 54016. Provider encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
Provider has designated Dr. Jill Zimmerman, President, as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 715-386-9011.
This Notice is effective April 14, 2003.
RECEIPT OF NOTICE OF PRIVACY PRACTICES
Client ID #:
My signature on this form acknowledges that I have received a
copy of Integra Counseling Services¡¦ Notice of Privacy
Practices. I understand that this document provides an
explanation of the ways in which my health information may be
used or disclosed by Integra Counseling Services and of my
rights with respect to my health information.
I have been provided with the opportunity to discuss any
concerns I may have regarding the privacy of my health
Client's Signature Date
Signature of Client's Representative Date
if client is unable to sign
TO BE COMPLETED BY ADMITTING THERAPIST IF FORM IS NOT SIGNED
1. Was the patient provided with a copy of the Notice of
__ Yes __ No
2. Briefly describe the efforts made to obtain the client's
acknowledgement of receipt of the Notice and explain why
the client was unable or unwilling to sign this form: