Protected Health Information Practices
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Christian Counseling Center we are committed to obtaining, treating, and using protected health information about you responsibly. This Notice of Protected Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective 4/14/03, and applies to all protected health information as defined by federal regulations. We reserve the right to change this Notice and make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.
Each time you visit Christian Counseling Center a record of your visit is made. Typically this record contains a history and description of the current reasons for seeking counseling, diagnoses, and a plan for future care or treatment goals. We need this record to provide you with quality care and to comply with certain legal requirements.
Although your health record is the physical property of Christian Counseling Center, the information belongs to you. You have the right to:
Christian Counseling Center is required to:
We will not use or disclose your health information without your authorization, except as described in this Notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
We will use your health information for treatment. For example: Information obtained by the therapist or other member of the health care team will be recorded in your record and used to determine the course of treatment that should work best for you, how you are responding to treatment and document any actions taken.
We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis and the treatment provided.
We will use your health information for regular operations. For example: Members of the clinical staff or management may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
Business Associates: There are some services provided in our organization through contacts with business associates. This may include but is not limited to computer support. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we’ve asked them to do. To protect your Health information, however, we require the business associate to appropriately safeguard your information.
Notification: We may use or disclose your information to notify you of appointment changes.
Marketing: 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.
Workers’ Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
If you have questions and would like additional information, you may contact the Center’s Privacy Officer at (270) 442-5738.
If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
I acknowledge that I have received a copy the Notice of Christian Counseling Center’s Protected Health Information Practices, which provides a detailed description of the uses and disclosures allowed, as well as other rights I have regarding my protected health information.
Signature of Patient, Guardian, or Personal Representative Date