THIS NOTICE DESCRIBES HOW TREATMENT INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. BY LAW, WE ARE REQUIRED TO INFORM YOU OF OUR DUTIES AND RESPONSIBILITIES RELATED TO DISCLOSURE OR USE OF YOUR PROTECTED HEALTH INFORMATION.

Effective Date: July 30, 2013

We respect your confidentiality and only release treatment information about you in accordance with Illinois and/or Federal law. Specifically, the Federal regulations of Confidentiality of Alcohol and Drug Abuse Patient Records and the Illinois Department of Mental Health and Developmental Disabilities Confidentiality Act and the Health Insurance Portability and Accountability Act (HIPAA)control the release of treatment information. This notice of privacy practice describes our policies related to the use of the records of your care that are generated by NCBHS, Inc.

Privacy Contact. If you have any questions about this notice or your rights or want additional copies, contact the agency’s Privacy Officer at 1-815-434-4727, ext. 217.

USE AND DISCLOSURE OF PROTECTED TREATMENT INFORMATION

In order to effectively provide you care, there are times when we will need to provide your treatment information with others beyond our practice.

Treatment. We may use or disclose treatment information about you to provide, coordinate, or manage your care or any related services.

Payment. Information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned reatment or for billing purposes if applicable

Healthcare Operations. We may use information about you to coordinate our business activities. This may include operations such as setting up your appointments, reviewing your care, or training staff. We may at times enter into Business Associate Agreements with companies/organizations to perform these tasks. These Business Associates enter into a agreement with us to appropriately safeguard your information in the course of doing their work

Marketing. North Central does not sell Protected Health Information. In the event we would be using PHI for marketing purposes we would need to obtain your authorization and consent.

Breaches. By law we are required to protect your Protected Health Information; in the event of a breach, you will be notified via letter through first class mail.

Information Disclosed Without Your Consent. Under Illinois and Federal law, information about you may be disclosed without your consent in the following circumstances:

Emergencies. Sufficient information may be shared to address an immediate emergency you are facing. A disclosure of treatment information is required when there is a reasonable expectation that you are in imminent danger of self-harm, of harming others, or of being harmed by others; or you are clearly unable to provide for your own health and safety.

Follow-Up Appointments/Care. We may contact you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required by Law. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as in the case of communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.

Coroners, Funeral Directors, and Organ Donation. We may disclose treatment information to a coroner or medical examiner and funeral directors for the purposes of carrying out their duties. When organs are donated sufficient information will be provided to the program as necessary to facilitate the organ or tissue donation.

Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure requirements. There also might be a need to share information with the Food and Drug Administration (FDA) related to adverse events or product defects. We are also required to share information, if requested with the Department of Health and Human Services (DHHS) to determine our compliance with Federal laws related to healthcare.

Criminal Activity or Danger to Others. If a crime is committed on our premises or against out personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.

YOUR RIGHTS

You have the following rights under Illinois and Federal law:

Copy of Record. You are entitled to inspect your treatment record NCBHS, Inc. has generated about you. We may charge you a reasonable fee for copying and mailing your record.

Note: You have the right to receive a copy of your records in a secure encrypted electronic format within 30 days of request, when records are within the electronic health record.

Release of Records. You may authorize in writing to release your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Restriction on Record. You may ask us not to use or disclose part of the treatment information. This request must be in writing. NCBHS, Inc. is not required to agree to your request if we believe it is not in your best interest to permit use and disclosure of the information.

Note: You have the right to restrict PHI disclosure to a health plan when you pay out-of-pocket in full for services rendered.

Contacting You. You may request that we send information to another address or by alternative means. We will honor such requests as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct.

Amending Your Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this, contact the agency’s Privacy Officer. In certain cases, we may deny your request. If we deny your request for an amendment you have the right to file a statement that you disagree with us. We will then file our response and your statement and our response will be added to your record.

Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your treatment information, except for information we used for treatment, payment, or healthcare operations purposes of that we shared with you or your family, or information that you gave us specific to authorization to release. It also excludes information we were required to release. To receive information regarding disclosures made for a specific time period no longer than six (6) years and after April 14th, 2003, please submit your request in writing to the agency’s Privacy Officer. We will notify you of the cost involved in preparing this list.

Questions and Complaints. If you have any questions or have any complaints you may contact the agency’s Privacy Officer in writing at our office for further information. You also may complain to the Secretary of Health and Human Services if you believe NCBHS, Inc. has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Privacy. NCBHS, Inc. reserves the right to change its Notice of Privacy Practices based on the needs of NCBHS, Inc. and changes in Illinois and Federal law.