Notice of Privacy Policies – Limits of Confidentiality

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Confidentiality

As a rule, we will not disclose information about you or the fact that you are a patient, without your written consent. Our mental health electronic record-keeping system describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, we do not routinely disclose information in such circumstances, so we will require your permission in advance, either through your consent at the onset of services (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting your therapist.

II. “Limits of Confidentiality”

There are some important exceptions to this rule of confidentiality some because of policies in this agency and some required by law. If you wish to receive mental health services from HOPE, you must sign the attached form indicating that you understand and accept the policies about confidentiality and its limits. You will be informed of the limits during your intake session, , but you may reopen the conversation at any time during your counseling process. Your therapist may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required:

Emergency: If you are involved in a life-threatening emergency and your therapist cannot ask your permission, he or she will share information if it is believed you would have wanted your therapist to do so, or if believed it will be helpful to you.

Child Abuse Reporting: If your therapist has reason to suspect that a child is abused or neglected, he or she is required by law to report the matter immediately to either the Department of Children and Family Services in Illinois or Children Protective Services in Wisconsin depending upon which state you reside in.

Adult Abuse Reporting: If your therapist has reasons to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, your therapist is required by law to immediately make a report and provide relevant information to the appropriate Department of Welfare or Social Services.

Health Oversight: Professional ethics requires that psychotherapists report misconduct by a health care provider of their own profession. By policy, we also reserve the right to report misconduct by health care providers of other professions. If you describe unprofessional conduct by another mental health provider of any profession, your therapist is required to explain to you how to make such a report. If you are yourself a health care provider, your therapist is required by law to report to your licensing board that you are in treatment if he or she believes your condition places the public at risk.

Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization or a judge issues a court order. If your therapist receives a subpoena for records or testimony, we will notify you so you can file a motion to quash (block) the subpoena. Protections of privilege may not apply if an evaluation for a third party is requested or where the evaluation is court-ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety: If you communicate to your therapist a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and your therapist believes you have the intent and ability to carry out that threat immediately or imminently, your therapist is legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By the agency’s policy, we may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.

Workers Compensation: If you file a worker’s compensation claim, your therapist is required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

Records of Minors: There are several laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records. Other circumstances may also apply, and this will be discussed in detail if services are provided to minors.

Other uses and disclosures of information not covered by this notice or by the laws that apply to your therapist will be made only with your written permission.

III. Patient’s Rights and Provider’s Duties:

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information disclosed about you to someone who is involved in your care or the payment for your care. If you ask to disclose information to another party, you may request that limited information be disclosed. However, your therapist is not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell your therapist: what information you want to limit; whether you want to limit my use, disclosure, or both; and to whom you want the limits to apply.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing your therapist. Upon your request, the agency will send your bills to another address. You may also request that your therapist or this agency contact you only at work, or that you do not want a voice message left on your voice mail. To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, we will discuss with you the details of the accounting process.

Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, the agency may charge a fee for the costs of copying and mailing. Your therapist may deny your request to inspect and copy in some circumstances. Your therapist may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.

Right to Amend – If you feel that protected health information your therapist has about you is incorrect or incomplete, you may ask to amend the information. To request an amendment, your request must be made in writing and submitted to your therapist. In addition, you must provide a reason that supports s your request. Your therapist may deny your request if you ask him or her to amend information that 1) was not created by your therapist; 2) is not part of the medical information kept by your therapist; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.

Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: the agency reserves the right to change policies and/or to change this notice, and to make the changed notice effective for medical information your therapist already has about you as well as any information received in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. Copies of the current notice available on request.

Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to the office. You may also send a written complaint to the U.S. Department of Health and Human Services.