HIPAA Notice of Privacy Practices
ROGER SHAW COUNSELING
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The following is the Notice of Privacy Practices of Roger Shaw Counseling (RSC) and its sole therapist Roger A. Shaw MA, LMFT, as described in the Health Insurance Portability and Accountability Act of 1996 and regulations
promulgated there under, commonly known as HIPAA. HIPAA requires RSC to maintain the privacy of your personal health information and to provide you with notice of RSC’s legal duties and privacy policies with respect to
your personal health information.
RSC Pledge Regarding Medical Information
RSC understands that medical information about you and your health is personal. RSC is committed to protecting medical information about you. A record of the care and services you receive here is created. This record
is created to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by RSC.
This notice will tell you about the ways in which RSC may use and disclose your personal health information. RSC also describe your rights and certain obligations it has regarding the use and disclosure of personal health
RSC is required by law to:
Ø make sure that personal health information is kept private;
Ø give you this notice of our legal duties and privacy practices with respect to personal information about you; and
Ø follow the terms of the notice that are currently in effect.
Your Personal Health Information
RSC collects personal health information from you through treatment, payment and related healthcare operations, healthcare providers or health plans, or through other means, as applicable. Your personal health information that
is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including mental health care providers. The law specifically protects health information
that contains data, such as your name, address, social security number, and others, that could be used to identify you as the individual patient who is associated with that health information.
RSC must maintain the privacy of your personal health information and give you this notice that describes its legal duties and privacy practices concerning your personal health information. In general, when RSC releases your
health information, RSC must release only the information needed to achieve the purpose of the use or disclosure. However, all of your personal health information will be available for release to you, to a provider regarding
your treatment, or due to a legal requirement. RSC must follow the privacy practices described in this notice.
How we may use or Disclosure
Your Personal Health Information
Generally, RSC may not use or disclose your personal health information without your permission. Further, once your permission has been obtained, RSC must use or disclose your personal health information in accordance with the
specific terms of that permission. The following are the circumstances under which RSC is permitted by law to use or disclose your personal health information.
Uses and Disclosures Without Your Express Permission
Ø Treatment: For example, if a therapist decides to consult with another licensed health care provider about your condition, she/he would be permitted to use and disclose your personal health information,
which is otherwise confidential, in order to assist in the diagnosis or treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard because physicians and other health care providers need access to the full record and/or full and complete information in order to provide quality
care. The word “treatment” includes, among other things, the coordination and management of health care among health care providers or by a health care provider with a third party, consultations between health care
providers, and referrals of a patient for health care from one health care provider to another.
Ø Payment: If your health plan requests a copy of your health records, or a portion thereof, in order to determine whether or not payment is warranted under the terms of your policy or contract, RSC is
permitted to use and disclose your personal health information.
Ø Health Care Operations: RSC may need your diagnosis, treatment, and outcome information in order to improve the quality or cost of care RSC delivers. These quality and cost improvement activities may
include evaluating the performance of your therapist Roger Shaw, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.
Ø Appointment Reminders: Unless you object, RSC may use and disclose medical information to contact you as a reminder that you have an appointment with Roger Shaw.
Ø Treatment Alternatives: Unless you object, RSC may use and disclose medical information to tell you about or recommend possible treatment options or new services.
Ø Health-Related Benefits and Services : Unless you object, RSC may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Ø To those involved with your care or payment of your care: If people such as family members, relatives, or close personal friends are helping care for you or helping you pay your medical bills, RSC may
release important health information about you to those people. The information released to these people may include your location, your general condition, or death.
You have the right to object to such disclosure, unless you are unable to function or there is an emergency. In addition, RSC may release your health information to organizations authorized to handle disaster relief efforts so
those who care for you can receive information about your location or health status. RSC may allow you to agree or disagree orally to such release, unless there is an emergency.
Ø As required or permitted by law: Sometimes RSC must report some of your health information to state or federal legal authorities, such as law enforcement officials, court officials, or government
agencies. For example, RSC may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
Ø For public health activities: RSC may be required to report your health information to authorities to help prevent or control disease, injury, or disability. This may include using your medical
record to report certain diseases, injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child or elder abuse or neglect.
Ø For health oversight activities: RSC may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for
government benefit programs. The Illinois Department of Professional Regulation, who license Professional Counselors, is an example of a health oversight agency.
Ø For activities related to death: RSC may disclose your health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death, such as identifying
the body, determining cause of death, or in the case of funeral directors, to carry out funeral preparation activities.
Ø To avoid a serious threat to health or safety: As required by law and standards of ethical conduct, RSC may release your health information to the proper authorities if RSC believes, in good faith, that
such release is necessary to prevent or minimize a serious and approaching threat to your or the public’s health or safety.
Ø For military, national security, or incarceration/law enforcement custody: If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement
officials or an inmate in a correctional institution, RSC may release your health information to the proper authorities so they may carry out their duties.
Ø For workers’ compensation: RSC may disclose your health information to the appropriate persons in order to comply with the laws related to workers’ compensation or other similar programs.
Ø Lawsuits and Disputes : If you are involved in a lawsuit or a dispute, RSC may disclose medical information about you in response to a court or administrative order, subpoena or discovery request
only if we have first given you notice of the order, subpoena or discovery request and an opportunity to quash it.
other uses and disclosures
The above list is not an exhaustive list, but informs you of most circumstances when disclosures without your written authorization may be made. Uses and disclosures for purposes other than described above require your express
authorization. Uses or disclosures made with your written authorization will be limited in scope to the information specified in the authorization form. You have the right to revoke an authorization at any time, except to
the extent that we have already taken action in reliance on your written authorization. Your revocation of an authorization must be in writing.
If Illinois law protects your confidentiality or privacy more than the federal “Privacy Rule” does, or if Illinois law gives you greater rights than the federal rule does with respect to access to your records, RSC
will abide by Illinois law.
In general, uses or disclosures by RSC of you personal health information will be limited to the minimum necessary to accomplish the intended purpose of the use or disclosure. As mentioned above, the “minimum
necessary” standard does not apply to disclosures to or requests by a health care provider for treatment purposes because health care providers need complete access to information in order to provide quality care.
Your Health Information Rights
You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact Roger Shaw at 12 Riggs Drive, Lincoln , Illinois 62656. Specifically, you have the right
Ø Inspect and copy your health information : You have the right to inspect and obtain a copy of your personal health information by making a specific request to do so in
writing. However, therapists are permitted to deny access for specified reasons. For instance, this right of access does not include psychotherapy notes or information gathered for judicial proceedings.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Roger Shaw at 12 Rigg Drive, Lincoln, Illinois 62656 . In addition, we may charge you a reasonable fee
if you want a copy of your health information.
Ø Request to amend your health information : If you believe your health information is incorrect, you may ask us to correct the information for as long as it is kept by RSWC. To
request an amendment, you must make your request in writing to Roger Shaw at 12 Rigg Drive, Lincoln, Illinois 62656. You must also give a reason as to why your health information should be changed.
RSC may deny your request for an amendment if it is not in writing or if it does not include a reason to support the request. RSC may also deny your request if RSC did not create the health information that you believe is
incorrect; if RSC disagrees with you and believes your health information is correct; if the information is not part of the information which you would be permitted to inspect or copy ( i.e. , psychotherapy notes); or, if
the information is not kept by or for RSC.
Ø Request restrictions on certain uses and disclosures : You have the right to ask for restrictions on the medical information RSC uses or discloses about you for treatment, payment or
health care operations. You also have the right to limit the health information provided to family or friends involved in your care or payment of medical bills. For example, you could ask that RSC not use or disclose
information about a particular procedure you underwent. You may also want to limit the health information provided to authorities involved with disaster relief efforts.
To request a restriction, you must make your request in writing to Roger Shaw at 12 Rigg Drive, Lincoln, Illinois 62656 . However, RSC is not required to agree in all circumstances to your requested restriction. If RSC does
agree, RSC will comply with your request unless the information is needed to provide you with emergency treatment.
Ø As applicable, receive confidential communication of health information : You have the right to ask that RSC communicate your health information to you in different ways or
places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. RSC must accommodate reasonable requests.
Ø Receive an accounting of disclosures of your health information : In some limited instances, you have the right to ask for a list of the disclosures of your health information RSC has
made during the previous six years, but the request cannot include dates before April 14, 2003. This list must include the date of each disclosure, who received the disclosed health information, a brief description of the
health information disclosed, and why the disclosure was made. RSC must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and RSC may not charge you for the list, unless you request
such list more than once per year.
RSC may deny your request if the disclosures made by RSC pertain only to: (a) treatment, payment and health care operations; (b) individuals who request their own health information; (c) include in the facility’s
directory or to those involved in the patient’s care; (d) comply with national security or intelligence purposes; (e) correctional institutions or law enforcement officials; or (e) have only disclosures made prior to April 14,
Ø Obtain a paper copy of this notice : Upon your request, you may at any time receive a paper copy of this notice from Roger Shaw ,
Ø Complain: If you believe your privacy rights have been violated, you may file a complaint with RSC and with the federal Department of Health and Human Services. To file a complaint with either entity,
please contact Roger Shaw, who will provide you with the necessary assistance and paperwork.
The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.
Changes to this Notice
RSC reserves the right to change the privacy practices described in this notice, in accordance with the law. Changes to privacy practices would apply to all health information maintained
IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING YOUR PRIVACY RIGHTS OR THE INFORMATION IN THIS NOTICE, PLEASE CONTACT Roger shaw at 12 rigg drive, Lincoln, Illinois 62656 FOR FURTHER INFORMATION AND RECEIPT OF COMPLAINTS.
HIPPA NOTICE OF PRIVACY PRACTICES
ROGER SHAW COUNSELING
By signing below, I confirm that ROGER SHAW COUNSELING has made available a copy of HIPPA Notice of Privacy Practices
and has provided a copy on his website @
Signature of Client or Guardian
Signature of Client ( if more than one client )
Roger Shaw LMFT
Signature of Witness