NOTICE OF PRIVACY PRACTICES
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Specialized Forensic Unit PC is committed to protecting the privacy of your personal and health information. At Specialized Forensic Unit PC, we are committed to protecting the confidentiality of individuals’ test results and other patient protected health information (PHI) that we collect or create as part of our services.
We urge you to read this Notice of Privacy Practices carefully so that you will understand both our commitment to the privacy of your PHI, and how you can participate in that commitment. Should you have any questions about this Notice or our privacy practices, please call us at 1-800-488-9790, send an email to firstname.lastname@example.org, or write to us at the following address:
Specialized Forensic Unit PC
3024 North Ashland Avenue, # 8432
Chicago, Illinois 60657-3012
Specialized Forensic Unit PC and its employees or independent contractors are committed to obtaining, maintaining, using, and disclosing patient’s protected health information (PHI) in a manner that protects patient’s privacy. We will only use or disclose the minimum amount of your PHI we consider necessary to perform a job or complete an activity. This Notice applies to all PHI that we maintain.
Specialized Forensic Unit PC is required by law to provide you with this Notice of Privacy Practices with respect to PHI, to maintain the privacy of PHI, to state the uses and disclosures of PHI that Specialized Forensic Unit PC may make, and to list the rights of individuals and our legal duties with respect to their PHI. Your PHI at Specialized Forensic Unit PC includes personal and medical information (such as your name, address, date of birth, testing results, etc.) that we obtain from you, your physician, health plan, or other sources. Your PHI also includes the results of your psychological testing and interview notes.
Specialized Forensic Unit PC is required to abide by the terms of the Notice of Privacy Practices currently in effect. Specialized Forensic Unit PC reserves the right to change the terms of this Notice of Privacy Practices and to make the provisions of the new Notice of Privacy Practices effective for all PHI that we maintain. The current Notice will be displayed on Specialized Forensic Unit PC website and a paper copy is available upon request.
HOW SFU MAY USE AND DISCLOSE YOUR PHI
Your PHI will be used or disclosed for treatment, payment or healthcare operations purposes and for other purposes permitted or required by law. Not every use or disclosure is listed; however, all of the ways we use or disclose your PHI will fall into one of the categories listed below.
“Use” applies only to activities within Specialized Forensic Unit PC, including independently contracted personnel bound by confidentiality contracts. “Use” includes sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure“ applies to activities outside of Specialized Forensic Unit PC, such as releasing, transferring, or providing access to information about you to other parties.
“Authorization“ is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form (e.g., Specialized Forensic Unit PC uses the Authorization to Release Records form). You have the right to revoke your authorization at any time, except if we have already made a disclosure based on that authorization.
Specialized Forensic Unit PC may use or disclose your PHI in the course of activities necessary to support our healthcare operations, such as performing quality checks on our testing, for teaching purposes or for developing normal reference ranges for tests that we perform.
Specialized Forensic Unit PC does not need your authorization or permission to use or disclose your PHI for the following purposes:
“Treatment” is when Specialized Forensic Unit PC provides, coordinates, or manages your health care and other services related to your health care (i.e., when Specialized Forensic Unit PC consults with another health care provider, such as your family physician or another psychologist).
“Payment“ is when Specialized Forensic Unit PC obtains reimbursement for your healthcare (i.e., when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage).
“Health Care Operations“ are activities that relate to the performance and operation of Specialized Forensic Unit PC (i.e., quality assessment and improvement activities, business-related matters of audits and administrative services, and case management and care coordination).
DISCLOSURES TO BUSINESS ASSOCIATES
Specialized Forensic Unit PC may disclose your PHI to other companies or individuals who need your PHI in order to provide specific services to us. These other entities, known as “business associates,” must comply with the terms of a contract designed to ensure that they will maintain the privacy and security of the PHI Specialized Forensic Unit PC provides to them or which they create on Specialized Forensic Unit PC behalf. Specialized Forensic Unit PC’s business associates must only use your PHI for designated treatment, payment, or health care operations purposes that they perform on our behalf. For example, Specialized Forensic Unit PC may disclose your PHI to temporary employees or independent contractors (i.e., psychological associates, psychological technicians, editors, etc).
AS PERMITTED OR REQUIRED BY LAW
Specialized Forensic Unit PC may use or disclose your PHI for various public policy purposes that are authorized or required by federal or state law. For example, Specialized Forensic Unit PC is required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services (“HHS”) upon request. Specialized Forensic Unit PC must provide you with copies of your PHI at your request, except when restricted or prohibited by state law. Specialized Forensic Unit PC will provide the information regarding your specific state to you upon request.
OTHER USES AND DISCLOSURES REQUIRING AUTHORIZATION
Specialized Forensic Unit PC may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances, when Specialized Forensic Unit PC is asked for information for purposes outside of treatment, payment, or health care operations, Specialized Forensic Unit PC will obtain an authorization from you before releasing this information. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that Specialized Forensic Unit PC have relied on that authorization; or if the authorization was obtained as a condition of obtaining insurance coverage.
OTHER USES AND DISCLOSURES WITHOUT AUTHORIZATION
Specialized Forensic Unit PC may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If Specialized Forensic Unit PC knows or has cause to suspect that a child has been abused or neglected, Specialized Forensic Unit PC must report the matter to the appropriate authorities as required by law.
Adult and Domestic Abuse: If Specialized Forensic Unit PC suspects that an adult has been abused, neglected, or exploited and Specialized Forensic Unit PC has cause to suspect that the adult is incapacitated or dependent, Specialized Forensic Unit PC must report the matter to the appropriate authorities as required by law.
Health Oversight Activities: Specialized Forensic Unit PC may disclose PHI to the state psychology board, or one of its representatives, pursuant to standards or regulations for regulation, accreditation, licensure, or certification.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and Specialized Forensic Unit PC will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If, in Specialized Forensic Unit PC’s professional judgment, you pose a direct threat of imminent harm to the health or safety of any individual, including yourself, Specialized Forensic Unit PC may disclose PHI to the appropriate persons.
Worker’s Compensation: Specialized Forensic Unit PC may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, Specialized Forensic Unit PC is not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a professional at our agency. On your request, Specialized Forensic Unit PC may send your bills to another address.
Right to Inspect and Copy: You (or your authorized or designated personal representative) have the right to inspect and/or obtain a copy of your PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Specialized Forensic Unit PC may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. Specialized Forensic Unit PC must permit you to request access to inspect and/or to obtain a copy of Psychotherapy Notes, unless Specialized Forensic Unit PC believes that such access would be detrimental to your health. If you are denied access to Psychotherapy Notes, it is possible, upon presentation of a written authorization signed by you, that such notes or a “narrative” of the notes may be made available to your “authorized representative.” Specialized Forensic Unit PC can discuss the details of the request and denial process.
Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Specialized Forensic Unit PC may deny your request. On your request, Specialized Forensic Unit PC will discuss with you the details of the amendment process.
Right to an Accounting: You have the right to receive an accounting of disclosures of your PHI that were made by Specialized Forensic Unit PC for a period of up to six years prior to the date of your written request. Under the law, this accounting does not include disclosures made for purposes of treatment, payment, health care operations, or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health reporting or in response to a court order.
Right to a Paper Copy: You have the right to obtain a paper copy of the notice from Specialized Forensic Unit PC upon request, even if you have agreed to receive the notice electronically.
Specialized Forensic Unit PC is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. Specialized Forensic Unit PC reserves the right to change the privacy policies and practices described in this notice. Unless Specialized Forensic Unit PC notifies you of such changes, however, Specialized Forensic Unit PC is required to abide by the terms currently in effect.
NOTE REGARDING STATE LAW
For all of the above purposes, in cases where state law is more restrictive than federal law, Specialized Forensic Unit PC is required to follow the more restrictive state law.
HOW TO CONTACT US
If you have questions or concerns regarding the privacy or confidentiality of your PHI, or you wish to register a complaint, please contact Specialized Forensic Unit PC by writing to the address located at the beginning of this notice, by calling at 1-800-488-9790, or by sending an email to email@example.com. Specialized Forensic Unit PC reserves the right to amend this Notice of Privacy Practices, at any time, to reflect changes in our privacy practices, and these changes will apply retroactively. Any such changes will be applicable to and effective for all Protected Health Information (PHI) that we maintain including PHI we created or received prior to the effective date of the Notice revision.