Notice of Privacy Practices

ECH Counseling LLC
44 N Virginia Street, Suite 3B, Crystal Lake, IL 60014
815-363-0864
info@echcounseling.com

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED.  ALONG WITH HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I will create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records generated by this private practice and tells you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. 

I am required by law to:

 Make sure that protected health information (PHI) that identifies you is kept private.

 Give you this notice of my legal duties and privacy practices with respect to health information.

 Follow the terms of the notice that is currently in effect.

 I can change the terms of this notice and such changes will apply to all information I have about you. The new notice will be provided, available upon request, and on our website.

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

Authorization and Consent: Except for areas identified in this notice, we will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.

Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. 1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:
   2. For my use in treating you.
   3. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
   4. For my use in defending myself in legal proceedings instituted by you.
   5. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
   6. Required by law and the use or disclosure is limited to the requirements of such law.
   7. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
   8. Required to help avert a serious threat to the health and safety of others.

1. 1. Marketing Purposes. As a counselor, I will not use or disclose your PHI for marketing purposes.
   2. Sale of PHI. As a counselor, I will not sell your PHI.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION:

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

• 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.

• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyoneʼs health or safety.

• For health oversight activities, including audits and investigations.

• For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• For research purposes, including studying and comparing the mental health of clients who received one form of therapy versus those who received another form of therapy for the same condition.
• For workers‘ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers‘ compensation laws.
• Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:

We may from time to time disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. 

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
• The Right to Request Restrictions for Out–of–Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your 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.
• The Right to Choose How I Send PHI to You: You have the right to ask me to contact you in a specific way or to send mail to a different address and I will agree to all reasonable requests.
• The Right to See and Get 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 I have about you. I 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, I may charge a reasonable, cost-based fee for doing so.

• The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of

instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last 7 years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

• 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 I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
• The Right to Get a Paper or Electronic Copy of this Notice: You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e–mail. And, even if you have agreed to receive this Notice via e–mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

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 checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.