HIPAA Notice of Privacy Practices

This notice informs you of how medical information regarding you may be used and disclosed and how you can access this information. Please review it carefully and consult your clinician with any questions you may have.

CWC Psychotherapy PLLC (“Clinician”) understands that information about your health care and yourself is personal. Clinician is committed to protecting your health information.

Clinician creates a record of the care and services you receive from Clinician, which is needed to provide quality care and to comply with certain legal requirements. These practices apply to all of the records of your care generated by Clinician and explain the ways in which Clinician may use and disclose health information about you.

These practices also describe your rights to the health information Clinician keeps about you and certain obligations Clinician has regarding the use and disclosure of your health information.

Clinician is required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• Give you this notice of Clinician’s legal duties and privacy practices with respect to health information, and follow the terms of Clinician’s latest practices.
• Not share your information other than as described in this notice without your written consent.

Clinician can change the terms of these privacy practices so long as the changes comply with the law, and such changes will apply to all information Clinician has about you. The new practices will be available upon request.

Clinician typically uses your protected health information in the following ways:

1. Treatment: Clinician may disclose your protected health information for treatment provided by Clinician and the treatment activities of any health care Clinician.

For example, if a Clinician were to consult with another licensed health care Clinician about your condition, Clinician would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the Clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care Clinicians need access to the full record and/or full and complete information in order to provide quality care.

The word “treatment” includes, among other things, the coordination and management of health care Clinicians with a third party, consultations between health care Clinicians, and referrals of a patient for health care from one health care Clinician to another.

2. Payment: Clinician may disclose protected health information for payment. For example, to our business associates in order to receive payment through insurance.

3. Health Care Operations: Clinician may use your protected health information for operational purposes, such as appointment reminders, to evaluate the performance of Clinician’s staff, assess the quality of services and outcomes, and learn how to improve Clinician’s services.

Clinician may also use your protected health information in the following ways:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition
4. For health oversight activities, including audits and investigations.
5. In situations where Clinician believes there may be abuse or neglect, to a public health authority that is authorized by law to receive reports of child abuse or neglect.
6. To a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
7. For judicial and administrative proceedings, including responding to a court or administrative order.
8. For law enforcement purposes, including reporting crimes occurring on Clinician’s premises.
9. To coroners or medical examiners, when such individuals are performing duties authorized by law.
10. If you are an organ donor, to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation
11. For research purposes, using only de-identified information, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
12. Specialized government functions, such as military, national security, and presidential protective services; or, helping to ensure the safety of those in correctional institutions.
13. For workers’ compensation purposes.
14. Appointment reminders and health related benefits or services. Clinician may use and disclose your PHI to contact you to remind you that you have an appointment with Clinician. Clinician may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that Clinician offers.
15. Clinician may also provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, however, you will have the opportunity to object (in whole or in part). The opportunity to consent may be obtained retroactively in emergency situations.
16. When required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500, et seq.

You have the following rights with respect to your PHI:

1. The Right to Request Limits. You have the right to ask Clinician not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Clinician is not required to agree to your request, and Clinician may say “no” if Clinician believes it would affect your health care.
2. The Right to Request Restrictions for Paid Out-of-Pocket Expenses. You have the right to request restrictions on disclosures of PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How Clinician Sends PHI to You. You have the right to ask Clinician to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and Clinician will agree to all reasonable requests.
4. The Right to See and Receive Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that Clinician has about you.

   Clinician will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request. Clinician may charge a reasonable, cost-based fee for doing so.

5. The Right to Receive a List of the Disclosures Clinician Has Made. You have the right to request a list of instances in which Clinician has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided Clinician with an Authorization. Clinician will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list Clinician will give you will include disclosures made in the last six years unless you request a shorter time. Clinician will provide the list to you at no charge, but if you make more than one request in the same year, Clinician will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that Clinician correct the information or add the missing information. Clinician may say “no” but will tell you why in writing within 60 days of receiving your request.
7. The Right to Receive a Paper or Electronic Copy of this Acknowledgement. You have the right to receive a paper and/or email copy of this Acknowledgement and to request a paper copy at any time.
8. Right to be Notified of a Breach. You have the right to be notified if Clinician or a business associate of Clinician discovers a breach of unsecured protected health information.
9. The Right to Choose Someone to Act for You. Someone with medical power of attorney or a legal guardian can exercise your rights and make choices about your health information.
10. Illinois Law. Illinois law also has certain requirements that govern the use or disclosure of your PHI. For Clinician to release information about mental health treatment, genetic information, your AIDS/HIV status, and alcohol or drug abuse treatment, you will be required to sign an authorization form unless state law allows Clinician to make the specific type of use or disclosure without a separate authorization.
11. File a Complaint if You Feel Your Privacy Rights Have Been Violated.

You may file a complaint with the Clinician by contacting us at:

CWC Psychotherapy PLLC
25 E Washington St, Ste 1606, Chicago, IL 60602
Ph. 312-725-8060
Email: admin@cwcpsychotherapy.com

You may also file a complaint with the U.S. Department of Health and Human Services by sending a letter to: 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. Clinician will not retaliate against you for filing a complaint.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you:

• Have received a copy of this HIPAA Notice of Privacy Practices.
• Have read and fully understand and agree to the privacy practices in this notice.
• You can contact Christine Weible-Cruz at [christine@cwcpsychotherapy.com, or 312-725-8060] if you have any questions about this notice.
• Have the right to refuse to sign this notice.