NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: April 14, 2003.

We respect patient confidentiality and only release medical information about you in accordance with Illinois and federal law. This notice describes our policies related to the use of the records of your care generated by Community Mental Health Council, Inc.

Privacy Contact. If you have additional questions about this policy or your rights contact:

• Director of Information Services, (773) 734-4033, ext. 183
• Co-Team Leader, Information Services (South) (773) 734-4033, ext. 214
• Co-Team Leader, Information Services (West) (773) 863-9749, ext. 159


USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

In order to effectively provide you care, there are times when we will need to share your medical information with others outside of Community Mental Health Council, Inc. This includes for:

Treatment. We may use or disclose medical information about you to provide, coordinate or manage your care or any related services, including sharing information with others outside CMHC that we are consulting with or referring you to.

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 treatment or for billing purposes.

Healthcare Operations. We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care and training staff.

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 the immediate emergency you are facing.

Follow-Up Appointments/Care. We will be contacting 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. We will leave appointment information on your answering machine, unless you advise us to do otherwise.

As Required by Law. This would include situations where we have a subpoena or court order, or are mandated to provide public health information, such as 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 medical 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. There also might be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested, with the Department of Health and Human Services to determine our compliance with federal laws related to health care.

Criminal Activity or Danger to Others. If a crime is committed on our premises or against our 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.

Fundraising. As a not-for-profit provider of health care services, we need assistance in raising money to carry out our mission. We may contact you to seek a donation.

PATIENT RIGHTS

You have the following rights under Illinois and federal law:

Copy of Records. You are entitled to inspect the medical records CMHC has generated about you. We may charge you a reasonable fee for copying and mailing your records.

Release of Records. You may consent 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 that no action has been taken in reliance on your prior authorization.

Restriction on Records. You may ask us not to use or disclose part of your medical information. This request must be in writing. CMHC is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information. The request should be given to the Privacy Contact.

Contacting You. You may request that we send information to another address or by alternative means. We will honor the request as long as it is reasonable and we are assured it is correct. We have a right under law to verify that the payment information you are providing is correct. We can also provide you information by e-mail if you request it. If you wish to communicate by e-mail, you are also entitled to a paper copy of this privacy notice.

Amending Records. If you believe that something in your records is incorrect or incomplete, you may request that we amend it. To do this, contact the Privacy Contact and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment, you have a right to file a statement that you disagree with us. We will then file our response; your statement and our response will be added to your records.

Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your medical information, except for information we used for treatment, payment or health care operations purposes, or that we shared with you or your family, or information that you gave us specific consent 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 years and after April 14, 2003, please submit your request in writing to our Privacy Contact. We will notify you of the cost involved in preparing this list.

Questions and Complaints. If you have any questions, wish a copy of this Policy or have any complaints, you may contact our Privacy Contact in writing at our office for further information. You may also contact the U.S. Secretary of Health and Human Services if you believe CMHC has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Policy. CMHC reserves the right to change its Privacy Policy based on the needs of CMHC and changes in state and federal law.