Anne Rossen, MA, LCPC
Anne Rossen Integrative Psychotherapy and More, LLC
By Appointment Only
666 Dundee Rd., Suite 704, Northbrook, IL 60062
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your Protected Health Information and My Responsibilities Regarding It
I am required by the laws and standards of the counseling profession to keep client records. These records contain personal and protected health information about you (for example, your name and address, your reason for seeking counseling, plans developed to help you meet your goals, your progress toward achieving those goals, and payment information). I am required by law to maintain the privacy and security of your protected health information and to let you know promptly if a breach occurs that may compromise the privacy and security of this information. I am also required to share with you, in the form of this Notice of Privacy Practices, my policies and procedures regarding the use and disclosure of your protected health information and your rights with regard to it.
You can be assured that I take great care in protecting the privacy and security of your information electronically and otherwise. You can also be assured I will not release information about you other than as described in this Notice unless you authorize me in writing to do so. If you give me such authorization, you may change your mind at any time (though I ask that you let me know this in writing). If and when I release information about you, I will make every effort to limit it to the minimum necessary to accomplish the intended purpose.
I am legally bound to follow the practices described herein. I reserve the right to change my privacy practices at any time as permitted by law. Any changes would apply to protected health information already on file with me. Before the effective date of a material change, however, I will post a new Notice in my office and on my website and provide the new Notice to you in writing if you ask me to.
Uses and Disclosures of Your Protected Health Information for Purposes of Treatment, Payment, and Health Care Operations
I may use and disclose your protected health information for purposes of (1) your treatment, (2) payment of services rendered, and (3) healthcare operations.
(1) Treatment. During the course of your treatment with me I may use your protected health information to provide, coordinate, or manage your care and services. I may disclose your protected health information to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. If I wish to provide information about you for purposes of your treatment by another health care provider, I will have you sign an authorization for release of the information to be disclosed.
(2) Payment. With your consent, I will use your information to obtain payment for the services I provide you. This may include contacting your insurance company to verify your coverage and to process claims and collect fees. I may also provide your protected health information to business associates such as practice management and claims processing companies, whom I require to appropriately safeguard the privacy and security of your information.
(3) Health Care Operations. I may use information about you to run my practice, improve your care, and contact you when necessary. This may include setting up your appointments, reviewing your care, and training staff. It may also involve sharing your protected health information with my attorneys, accountants, consultants, and others to make sure I am in compliance with applicable laws and/or providing the best quality of care. Your written consent is not required in these instances. However, I require any such person or entity to appropriately safeguard the privacy and security of your information.
Other Uses and Disclosures of Your Health Information
Under Illinois and federal law, information about you may be disclosed in the following circumstances without your consent:
Emergencies. If you are facing an emergency and are not able to give or refuse permission, I may share sufficient information about you to enable you to receive emergency care.
Judicial and Administrative Proceedings. I may disclose your personal health information during the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for Workers Compensation.
Child and Elder Abuse or Neglect. As a mandated reporter of suspected child and elder abuse or neglect, I may disclose health information about you in the course of carrying out this duty.
Criminal Activity or Danger to Others. If a crime is committed on my premises or against personnel, or if I believe there is someone who is in imminent danger, I may share information with law enforcement officials.
Public Health Activities. If I believed you to be an immediate danger to yourself or others, I may disclose health information about you to the appropriate authorities, as well as alert any other person who may be in danger.
Health Oversight Activities. I may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. This includes investigations by the U.S. Department of Health and Human Services to determine whether I’m complying with federal privacy law.
Coroner’s Investigation. I may disclose information about the circumstances of your death to a coroner who is investigating it.
National Security, Intelligence Activities, and Protective Services to the President and Others. I may release health information about you to authorized federal officials as provided by law to protect the President or other national or international figures, or in cases of national security.
For Research Purposes. In certain circumstances I may provide your protected health information in order to conduct psychotherapy-related research. I would discuss this with you and seek your written authorization prior to releasing any information.
You have the following rights regarding your health information under Illinois and federal law:
Right to Inspect and Obtain a Copy of Your Record. You have the right to look at and receive a copy of the paper or electronic record of your treatment with me. If you ask for a copy of your record, I will provide it within 30 days of your request. I am allowed to charge you a reasonable, cost-based fee for doing this.
Right to Amend Your Record. If you believe that something in your record is incomplete or inaccurate, you may ask me to amend it. Your request must be made to me in writing. I may deny your request if I did not create the information you want changed, or for certain other reasons. If I deny your request, I will provide you with a written explanation within 60 days, to which you have the right to respond with a statement of disagreement. In such case, both your statement and my response will be added to your record. If I accept your request to change the information, I will make reasonable efforts to tell others, including people you name, of the amendment and to include the amendment in any future sharing of that information.
Right to Request Confidential Communications. You may ask me to communicate with you about your health matters in a certain way or at a certain location. For example, you may ask that I contact you at work instead of at home, or by email instead of by regular mail. I will honor all reasonable requests.
Right to Request Restriction on Use or Disclosure of Your Record. You may ask me not to use or disclose part of your record. This request must be made to me in writing. I am not required to agree to your request if I believe it is in your best interest to permit use and disclosure of the information, but I will consider your request very seriously. If I agree, I will abide by our agreement unless the information is needed in an emergency or disclosure is required by law. If you pay for a service or health care item out-of-pocket in full, you may ask me not to share that information for the purpose of payment or my health care operations with your health insurer. I will honor your request unless a law requires me to share that information.
Right to an Accounting of Disclosures. You have the right to receive a list of times that I shared your confidential information, with whom, and why. Such an accounting does not apply to instances in which your information was shared for treatment, payment, or health care operations purposes. Neither does it apply to information I shared with you or your family or to information that you gave me specific authorization to release. It also excludes information I was required to release for national security or law enforcement purposes. Your request for an accounting of disclosures must be made to me in writing. Such an accounting is available for disclosures made up to six years prior to the current request, and remains available for six years after your last date of service with me. I will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Right to a Paper or Email Copy of This Privacy Notice. You have the right to receive an electronic or paper copy of this Notice upon request.
Right to Consent to and Revoke Release of Your Record. You may consent in writing to release of your record to others, for any purpose you choose. This could include your attorney, employer, or anyone whom you wish to have knowledge of your care. You may revoke this consent at any time, in writing. Your revocation becomes effective upon my receipt of your request and applies to disclosures not already completed.
Right to 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 this person has the authority and can act for you before I take any action.
You also have the right to specify whether and how your information may be shared with a member of your family, a close friend, or another personwhom you tell me is involved in your care or responsible for the payment of your health care. I will follow your instructions.
Questions and Complaints
If you have any questions, or if you think I have violated your privacy rights, please contact me, Anne Rossen, at the address given at the top of this Notice. You may also file a complaint with 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 in any way for filing a complaint.
Effective Date of This Notice: September 23, 2013