of Privacy Practices/Protected Health Information ("PHI")
Your health record contains
personal information about you and your health. This information about you that
may identify you and that relates to your past, present or future physical,
mental health or condition and/or related health care services is referred to
as Protected Health Information (“PHI”).
This Notice of Private Practices describes how we may use and disclose
your PHI in accordance with applicable law including the Health Insurance
Portability and Accountability Act ("HIPPA") and the NASW Code of
Ethics. It also describes your rights regarding how you may gain access to
and control your PHI.
We are required by law to
maintain the privacy of PHI and to provide you with notice the legal duties and
privacy practices with respect to PHI.
We are required to abide by the terms of this Notice of Privacy
Practices. We reserve the right to
change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be
effective for all PHI that we maintain at that time. We will provide you with a copy of a revised
Notice of Privacy Practices upon your request, sending a copy to you in the
mail upon written request or providing one to you at your next appointment.
HOW WE MAY USE AND
DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are
involved in your care for the purpose of providing, coordinating, or managing
your health care treatment and related services. This includes consultation with clinical
supervisors or other treatment team members.
We may disclose PHI to any other consultant, only with your
authorization. We may also contact you
to remind you of your/your child's appointments or to provide information to
you about treatment alternatives or other health-related benefits and services
that may be of interest to you. Each time you visit Corri Ferdman, LCSW, LLC a
record of your visit is made. Typically, records may contain your symptoms,
observations made, statements you have reported, diagnoses, treatment, homework
assignments and/or a plan for future care or treatment.
For Payment. We may use and disclose PHI so that we can receive
payment for the treatment services provided to you. This will only be done with your
authorization. Examples of payment-related
activities are: making a determination of eligibility or coverage for insurance
benefits, processing claims with your insurance company, reviewing services
provided to you to determine medical necessity, or undertaking utilization
review activities. If it becomes necessary
to use collection processes due to lack of payment for services, we will only
disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care
Operations. We may use or
disclose, as needed, your PHI in order to support our business activities
including, but not limited to, quality assessment activities, employee review
activities, licensing, and conducting or arranging for other business
activities. For example, we may share your PHI with third parties that perform
various business activities (e.g., billing or typing services) provided we have
a written contract with the business that requires it to safeguard privacy of
your PHI. For training or teaching purposes PHI will be disclosed only with
Required by Law. Under the law, we must disclose your PHI to you upon
your request. In addition, we must make
disclosures to the Secretary of the Department of Health and Human Services for
the purpose of investigating or determining our compliance with the requirements
of the Privacy Rule.
Without Authorization. Following is a list of categories of uses and
disclosures permitted by HIPPA without an authorization. Applicable law and
ethical standards permit us to disclose information about you without your
authorization only in a limited number of situations. As a social worker
licensed in this state and as a member of the National Association of Social
Workers, it is our practice to adhere to more stringent privacy requirements
for disclosures without an authorization.
The following language addresses these categories to the extent
consistent with the NASW Code of Ethics and HIPPA.
Child Abuse or
Neglect. We may disclose your PHI to
a state or local agency that is authorized by law to receive reports of child
abuse or neglect.
Administrative Proceedings. We may
disclose your PHI pursuant to a subpoena (with your written consent), court
order administration order or similar process.
Patients. We may disclose PHI
regarding deceased patients as mandated by state law or to a family member that
was involved in your care or payment for care prior to death based on your
prior consent. A release of information
regarding the deceased patients may be limited to an executor of administrator
of a deceased person’s estate or the person identified as next-of-kin.
Emergencies. We may use or disclose
your PHI in a medical emergency situation to medical personnel, only in order
to prevent serious harm. Our staff will try to provide you a copy of this
notice as soon as reasonably practicable after the resolution of the
Involvement in Care. We may disclose
information to close family members or friends directly involved in your
treatment based on your consent or as necessary to prevent serious harm.
Oversight. If required, we may
disclose PHI to a health oversight agency for activities authorized by law such
as audits, investigations and inspections. Oversight agencies seeking this
information include government agencies and organizations that provide
financial assistance to the program (such as third-party pars based on your
prior consent) and peer review organizations performing utilization and quality
Enforcement. We may disclose PHI to a
law enforcement official as required by law, in compliance with a subpoena
(with your written consent), court order, administrative order or similar
document, for the purpose of identifying a suspect, material witness or missing
person in connection with a crime, in connection with a deceased person, in
connection with the reporting of a crime in an emergency or in connection with
a crime on the premises.
Government Functions. We may review
requests from the U.S. military command authorities if you have served as a
member of the armed forces authorized officials for national security and
intelligence reasons and to the Department of State for medical suitability
determinations, disclose your PHI based on your written consent, mandatory
disclosure laws and the need to prevent serious harm.
Public Health. If required, we may use or disclose our PHI for
mandatory public health activities to a public health authority authorized by
law to collect or receive such information for the purpose of preventing or
controlling disease, injury, or disability or if directed by a public health
authority, to a government agency that is collaborating with that public health
Public Safety. We may disclose your PHI if necessary to prevent or
lessen a serious and imminent threat to the health or safety of a person or the
public. If information is disclosed, it
will be disclosed to a person or persons reasonably able to prevent or lessen
the threat, including the target of the threat.
Research. PHI may only be disclosed after a special
approval process or with your authorization.
Fundraising. We may send you fundraising communications at
one time or another. You have the right to opt out of such fundraising
communications with each solicitation you receive.
Permission. We may also use or
disclose your information to family members that are directly involved in your
treatment with your verbal permission.
Authorization. Uses and disclosures not specifically
permitted by applicable law will be made only with your written authorization,
which may be revoked at any time, except to the extent that we have already
made a use or disclosure based upon your authorization. The following uses and disclosures will be
made only with your written authorization: (i) most uses and disclosures of
psychotherapy notes which are separated from the rest of your medical record;
(ii) most uses and disclosures of PHI for marketing purposes, including
subsidized treatment communications; (iii) disclosures that constitute a sale
of PHI; and (iv) other uses and disclosures not described in this Notice of
YOUR RIGHTS REGARDING
You have the following rights
regarding your PHI we maintain about you.
To exercise these rights, please submit your request in writing to Corri
Ferdman 900 North Shore Drive, Suite 106 Lake Bluff, IL 60044.
Access to Inspect and Copy. You have the
right, which may be restricted only in exceptional circumstances, to inspect
and copy PHI that is maintained in a “designated record set”. A designated record set contains mental
health/medical and billing records and any other records that are used to make
decisions about your care. Your right to
inspect and copy PHI will be restricted only in those situations where there is
compelling evidence that access would cause serious harm to you. We may charge
a reasonable, cost-based fee for copies.
If your records are maintained electronically, you may also request and
electronic copy of your PHI. You may also request that a copy of your PHI be
provided to another person.
Amend. If you feel that the PHI we
have about you is incorrect or incomplete, you may ask us to amend the
information although we are not required to agree to the amendment. If we deny your request for amendment, you
have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement
and will provide you with a copy. Please
contact Corri Ferdman if you have any questions.
Right to an
Accounting of Disclosures. You have
the right to request an accounting of the disclosures that we make of your
PHI. We may charge you a reasonable fee
if you request more than one accounting in any 12-month period.
Request Restrictions. You have the
right to request a restriction or limitation on the use or disclosure of your
PHI for treatment, payment or health care operations. We are not required to agree to your request
unless the request is to restrict disclosure of PHI to a health plan for
purposes of carrying out payment or health care operations and the PHI pertains
to a health care item or service that you paid for out of pocket. In that case, we are required to honor your
request for a restriction.
Request Confidential Communication.
You have a right to request that we communicate with you about medical matters
in a certain way or at a certain location. We may require information regarding
how payment will be handled.
Notification. If there is a breach of
unsecured PHI concerning you, we may be required to notify you of this breach,
including what happened and what you can do to protect yourself.
Right of a
Copy of this Notice. You have a right
to a copy of this notice.
NOTE: Records will be kept
a minimum of 7 years and possibly longer if you are a minor. Records will be
destroyed by using a shredding machine and/or in a fire place/pit.
you have any questions or believe we have violated your privacy rights, you
have a right to file a complaint and we ask that you first do so by calling the
office to speak with Mimi at (847) 793-0788.
If you feel the issue was not resolved please contact Corri at (847)
302-7778. You can also put your concerns
in writing and send it to Corri Ferdman at 900 North Shore Drive, Suite 106
Lake Bluff, IL 60044 or with the Secretary of Health and Human Services at 200
Independence Avenue, S.W. Washington D.C. 20201, or by calling
202-619-0257. The office will not retaliate against you for filing a
Receipt and Acknowledgment
ofHIPAA Notice of Patients Privacy Practices
understand my rights pertaining to this notice of privacy practices/protected
health information (PHI) and agree to my responsibilities as a patient
receiving services from Corri Ferdman LCSW, LLC.
I/We acknowledge that I/We have
been given an opportunity to read a copy of Corri Ferdman, LCSW, LLC’s Notice
of Privacy Practices. I/We also acknowledge that I have been offered
and declined and/or am in receipt of Corri Ferdman, LCSW, LLC privacy practice
notice. I may request an additional copy of the privacy practice notice at
Signature _______________________________________________ Date____________
Parent Signature if patient is under 18 _______________________________________________