 |
|
|
 |
Privacy Policy OUR PRIVACY POLICY This is the web site of Family Service & Mental Health Center of Oak Park & River Forest. Our postal address is: 120 S. Marion, Street, Oak Park, IL 60301. We can be reached via e-mail at admission@familyserviceoprf.com or you can reach us by telephone at 708-383-7500. For each visitor to our Web page, our Web server automatically recognizes the consumer's domain name, but not the e-mail address. We collect aggregate information on what pages consumers access or visit. We collect the e-mail addresses of those who communicate with us via e-mail for our use only. With respect to cookies: We do not set any cookies. With respect to security: We have appropriate security measures in place in our physical facilities to protect against the loss, misuse or alteration of information that we have collected from you at our site. If you feel that this site is not following its stated information policy, you may contact us at the above addresses or phone number. NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: 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 client confidentiality and only release confidential 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 this Agency. Privacy Contact. If you have any questions about this policy or your rights, contact the Clinical Director at 708/383-7500, extension 308. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION In order to effectively provide you care, there are times when we will need to share your confidential information with others beyond our Agency. This includes for: Treatment. We may use or disclose treatment information about you to provide, coordinate, or mange your care or any related services, including sharing information with others outside our Agency that we are consulting with or referring you to. Payment. With your written consent, 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, 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 tell us not to. As Required by Law. This would include situations where we have a subpoena, 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. We are required to disclose information about the circumstances of your death to a coroner who is investigating it. Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. We are also required to share information, if requested, with the U.S. Department of Health and Human Services to determine our compliance with federal laws related to health care and to Illinois state agencies that fund our services. 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. CLIENT RIGHTS You have the following rights under Illinois and federal law: Copy of Record. You are entitled to inspect the client record our Agency has generated about you. We will charge you $20.00 for copying and mailing your record. Release of Records. You may consent in writing to release of 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 no action has been taken in reliance on your prior authorization. Restriction on Record. You may ask us not to use or disclose part of the clinical information. This request must be in writing. The Agency 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 Clinical Director. Contacting You. You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. We also will be glad to provide you information by email if you request it. Amending Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this, contact the Clinical Director 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 you disagree with us. We will then file our response and your statement and our response will be added to your record. Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your confidential information, except for information we used for treatment, payment, or health care operation 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 disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Clinical Director. We will notify you of the cose involved in preparing this list. Questions and Complaints. If you have any questions, or wish a copy of this Policy or have any complaints, you may contact the Clinical Director in writing at our office for further information. You also may complain to the Secretary of U.S. Department of Health and Human Services if you believe our Agency has violated your privacy rights. We will not retaliate against you for filing a complaint. Changes in Policy. The Agency reserves the right to change its Privacy Policy based on the needs of the Agency and changes in state and federal law. CLIENT RIGHTS STATEMENT As a client of our Agency, you have the following rights:
FAMILY SERVICE & MENTAL HEALTH
CENTER CLIENT AGREEMENTS AND AUTHORIZATIONS CONSENT FOR TREATMENT. I hereby consent to the treatment provided by Family Service & Mental Health Center of Oak Park & River Forest and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs. (client initials) AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION. I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of the Agency. I authorize the Agency to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that the Agency may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent. (client initials) PRIVACY POLICY. I acknowledge having been offered the Agency's "Notice of Privacy Policies" and their "Client's Rights Statement." My rights including the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record, is explained in the Policy. My right to make a complaint and file a grievance under Illinois laws has also been explained. I understand that I may revoke in writing my consent for release of my health care information, except to the extent the Agency has already made disclosures with my prior consent. (client initials)
|
 |
 |
 |
 |
 |
