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NOTICE OF PRIVACY PRACTICES - UNBROKEN THERAPY

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.


I. Uses and Disclosures for Treatment, Payment, and Health Care Operations


Unbroken Therapy may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

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“PHI” refers to information in your health record that could identify you.

 

  • “Treatment, Payment, and Health Care Operations”

    • Treatment is when Unbroken Therapy provides, coordinates, or manages your health care and other services related to your health care. This includes consultations with another health care provider, such as your family physician or another psychologist.

    • Payment is when Unbroken Therapy obtains reimbursement for your healthcare. This includes disclosures of 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 Unbroken Therapy. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

  • Use” applies only to activities within the organization, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

  • “Disclosure” applies to activities outside of the organization, 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.


II. Other Uses and Disclosures Requiring Authorization


Unbroken Therapy 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 information for purposes outside of treatment, payment, or health care operations is required, Unbroken Therapy will obtain an authorization from you before releasing this information. An authorization is also required for release of “Psychotherapy Notes,” which are notes made about conversations during a private, group, joint, or family therapy session. These notes are given a greater degree of protection than PHI and must be kept separate from the rest of a client record.


You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Unbroken Therapy has taken action in reliance on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.


III. Uses and Disclosures without Authorization


Unbroken Therapy may use or disclose PHI without your consent or authorization in the following circumstances:

 

  • Child Abuse – If there is reasonable cause to believe a child known to anyone within the organization in a professional capacity may be an abused child or a neglected child, this must be reported to the appropriate authorities.

  • Adult and Domestic Abuse – If there is reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, this also must be reported to the appropriate authorities.

  • Health Oversight Activities – Unbroken Therapy may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.

  • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and Unbroken Therapy must not release such information without a court order. Unbroken Therapy can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.

  • Serious Threat to Health or Safety – If you communicate to any employee of Unbroken Therapy a specific threat of imminent harm against another individual or if there is evidence of clear, imminent risk of physical or mental injury being inflicted against another individual, Unbroken Therapy may make disclosures that are necessary to protect that individual from harm. Further, if there is evidence of an imminent, serious risk of physical or mental injury or death to yourself, Unbroken Therapy may make disclosures necessary to protect you from harm.

  • Worker’s Compensation – Unbroken Therapy may disclose protected health information regarding you 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.


IV. Patient’s Rights and Provider’s Duties


Patient’s Rights:

 

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, Unbroken Therapy 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 receiving services from Unbroken Therapy. On your request, Unbroken Therapy will send correspondence to another address.)

  • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in Unbroken Therapy's mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record and Psychotherapy Notes. 

  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record; however, Unbroken Therapy may deny your request. On your request, your provider will discuss with you the details of the amendment process.

  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.

  • Right to a Paper Copy – You have the right to obtain a paper copy of this notice upon request, even if you have agreed to receive the notice electronically.

  • Provider’s Duties:

  • Mental health providers are required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.

  • Unbroken Therapy reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, Unbroken Therapy is required to abide by the terms currently in effect.

  • If the policies and procedures in this notice are revised, Unbroken Therapy will provide clients with a revised notice of privacy policies and procedures by mail.


V. Questions and Complaints


If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact Unbroken Therapy directly for further information in the following ways:


Telephone: (773) 250-7981


Mail: 4305 N Lincoln Ave, Suite G, Chicago, IL 60618


Email: contact your provider directly


If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint directly to the office address above.


You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Unbroken Therapy can provide you with the appropriate address upon request.


You have specific rights under the Privacy Rule. Unbroken Therapy and its affiliates will not retaliate against you for exercising your right to file a complaint.


VI. Effective Date, Restrictions, and Changes to Privacy Policy


This notice will go into effect on November 1, 2020.

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