Heath Information Portability Accountability Act (HIPAA)
Your Rights
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.I will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.I may say “no” to your request, but I’ll tell you why in writing within 60 days.
Request confidential communications
You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.I will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and I may say “no” if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.I will make sure the person has this authority and can act for you before I take any action.
File a complaint if you feel your rights are violated
You can complain if you feel I have violated your rights by contacting InnerBloom Therapy Practice.You can file a complaint with the State of Illinois Department of Health, or the Secretary of the U.S. Department of Health and Human Services Office for Civil Rights 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/. I will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what I share.
If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions. In these cases, you have both the right and choice to tell me to:Share information with your family, close friends, or others involved in your careShare information in a disaster relief situationInclude your information in a hospital directoryIf you are not able to tell us your preference, for example if you are unconscious, I may go ahead and share your information if we believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.In these cases I never share your information unless you give us written permission:Marketing purposesSale of your informationMost sharing of psychotherapy notesIn the case of fundraising:I may contact you for fundraising efforts, but you can tell me not to contact you again.
Our Uses and Disclosures How do we typically use or share your protected health information?
Subject to HIPAA, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therin, I typically use or share your health information in the following ways.
Treat you
I can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run the organization
I can use and share your health information to run my practice, improve your care, and contact you when necessary. Example: I use health information about you to manage your treatment and services.
Bill for your services
I can use and share your health information to bill and get payment from health plans or other entities. Example: I give information about you to your health insurance plan so it will pay for your services.I may contract with business associates to do work directly for us related to your treatment; this may include billing, consultation, legal, and related business practices. In such circumstances, the business associate will be subject to a Business Associates Agreement which obligates any such associate to maintain privacy consistent with the state and federal requirements outlined herein.
How else can we use or share your health information?
I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html, and the Illinois Mental Health and Developmental Disabilities Confidentiality Act, state and federal alcohol and substance abuse privacy laws and the exceptions provided therin.
Help with public health and safety issues. Subject to certain exceptions, I can share health information about you for certain situations such as:Preventing diseaseHelping with product recallsReporting adverse reactions to medicationsReporting suspected abuse, neglect, or domestic violencePreventing or reducing a serious threat to anyone’s health or safety
Do research. I can use or share your information for health research.
Comply with the law. I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests. I can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director. I can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests. I can use or share health information about you: For workers’ compensation claimsFor law enforcement purposes or with a law enforcement officialWith health oversight agencies for activities authorized by lawFor special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions. I can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
I am required by law to maintain the privacy and security of your protected health information.I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.I must follow the duties and privacy practices described in this notice and give you a copy of it.I will not use or share your information other than as described here unless you tell us we can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, the new notice will be available upon request, in my office and on my website.
The privacy official:
Denise Gulotta, LCSW
InnerBloom Therapy Practice
2656 W. Montrose Ave. Suite 104
Chicago, IL 60618