Community Counseling Center


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This notice takes effect on October 12, 2002 and remains in effect until we replace it.
1. Our pledge regarding Protected Health Information (PHI):
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of protected health information.
2. Our Legal Duty LEGAL DUTY
Law Requires Us to:
1. Keep your protected health information private. 2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. 3. Follow the terms of the notice that is now in effect.
We Have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
3. Use and Disclosure of Your Protected Health Information
The following section describes different ways that we use and disclose protected health information. For each kind of use or disclosure, we will explain what we mean and give an example. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose protected health information. We will not use or disclose your information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us unless it is a non-revocable court release.
We may use protected health information about you to provide you with treatment or services. We may disclose protected health information about you to counselors, nurses, technicians, Interns, or other people who are taking care of you.
We may use and disclose your protected health information for payment purposes with your written authorization.
We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.
In addition to using and disclosing your protected health information for treatment, payment, and health care operations, we may use and disclose protected health information for the following purposes.
  • Disaster Relief: We may share protected health information with a public or private organization or person who can legally assist in disaster relief efforts.
  • Research in Limited Circumstances: We may use protected health information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of protected health information.
  • Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the protected health information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
  • Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
  • Court Orders and Judicial and Administrative Proceedings: We may disclose protected health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the protected health information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
  • Public Health Activities: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
  • Victims of Abuse, Neglect, or Domestic Violence: We may disclose protected health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
  • Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
  • Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
  • Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
  • Appointment Reminders: We may use and disclose protected health information for purposes of reminding you of your appointment.
  • Alternative and Additional Medical Services: We may use and disclose protected health information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
4. Your Individual Rights INDIVIDUAL RIGHTS
You Have a Right to:
  1. Look at or get copies of your protected health information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may schedule an appointment by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. We may request that you schedule an appointment to review your private health information in order that we may answer any questions you may have. If you request copies, we will charge you $.50 for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
  2. Receive a list of all the times we or our business associates shared your information for purposes other than treatment, payment, and health care operations and other specified exceptions.
  3. Request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
  4. Request that we communicate with you about your protected health information by different means or to different locations. Your request that we communicate your information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
  5. Request that we change your protected health information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
  6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.
  QUESTIONS AND COMPLAINTS If you think that we may have violated your privacy rights, contact the person named above. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. ACKNOWLEDGEMENT FORM I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.  
Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.