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Privacy Statement

I. This notice describes how health and service information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You should read this Notice before signing the Consent to the Use and Disclosure of Health Information for treatment, payment and health care operations of the Larkin Center.

II. Our Duty to Safeguard Your Protected Health Information.

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered "Protected Health Information" ("PHI"). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure.

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice at the reception desk. You may request a copy of the new notice from the front desk or our Privacy Officer who may be contacted as follows:

Martine Lyle, QA/Admissions Director
1212 Larkin Avenue
Elgin, IL 60123
Telephone: (847) 695-5656
Fax: (847) 695-0897

III. How We May Use and Disclose Your Protected Health Information.

We use and disclose PHI for a variety of reasons. For most uses/disclosures, we must obtain your consent. For others, we must have your written authorization. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following offers more description and examples of our potential uses/disclosures of your PHI.

§ Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Generally, we must have your consent to use/disclose your PHI:

o For services: We may disclose your PHI to staff members, volunteers, and other service delivery personnel who are involved in providing your services. For example, your PHI will be shared among members of your treatment team.
o To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your services. For example, we may release portions of your PHI to Medicaid, a private insurance plan, or a state office to get paid for services that we delivered to you.
o For service operations: We may use/disclose your PHI in the course of operating our agency. For example, we may use your PHI in evaluating the quality of services provided, or disclose your PHI to our accountant or attorney for audit purposes. We may disclose your PHI to designated staff in our central office for similar purposes. Release of your PHI to the county, state, and/or the Medicaid agency might also be necessary to determine your eligibility for publicly funded services.
o Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home.
o Exceptions: Although your consent is usually required for the use/disclosure of your PHI for the activities described above, the law allows us to use/disclose your PHI without your consent in certain situations. For example, we may disclose your PHI if needed for emergency treatment if it is not reasonably possible to obtain your consent prior to the disclosure and we think that you would give consent if able. Also, if we are required by law to provide your treatment, we may use/disclose your PHI for treatment, payment and operations without obtaining your prior consent.

§ Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Like consents, authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

§ Uses and Disclosures Not Requiring Consent or Authorization: The law provides that we may use/disclose your PHI without consent or authorization in the following circumstances:

o When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
o For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.
o For health oversight activities: We may disclose PHI to an accrediting organization or another agency responsible for monitoring our services for such purposes as reporting or investigation of unusual incidents.
o Relating to decedents: We may disclose PHI relating to an individual's death to coroners, medical examiners or funeral directors.
o For research purposes: In certain circumstances, and under supervision of a privacy board, we may disclose PHI to other agencies in order to assist medical/psychiatric research.
o To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
o For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.

§ Uses and Disclosures Requiring That You Have an Opportunity to Object: In the following situations, we may disclose your PHI if we inform you about the disclosure in advance and you do not object. However, if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

o To families, friends or others involved in your care: We may share with these people information directly related to your family's, friend's or other person's involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.

IV. Your Rights Regarding Your Protected Health Information. You have the following rights relating to your protected health information:

§ To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

§ To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.

§ To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, but may be waived, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

§ To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (i) correct and complete; (ii) not created by us and/or not part of our records, or; (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.

§ To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for which you gave consent (i.e. for treatment, payment, operations, to you, your family). The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or before April 14, 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

§ To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request. If you request an electronic copy via email, you must sign a consent form to allow us to communicate with you in that manner.

V. How to Complain about our Privacy Practices:

If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W.; Washington, DC 20201, or reach the Secretary by phone at (202) 690-7000. We will take no retaliatory action against you if you make such complaints.

VI. Contact Person for Information, or to Submit a Complaint:

If you have questions about this Notice or any complaints about our privacy practices, please contact:

Martine Lyle, QA/Admissions Director
1212 Larkin Avenue
Elgin, IL 60123
Telephone: (847) 695-5656
Fax: (847) 695-0897

VII. Effective Date: This Notice was effective on April 14, 2003.