Privacy Policies

A downloadable pdf of the privacy policies are located here: NOTICE OF PRIVACY PRACTICES REV 9-20-13

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.

Your Health Record
Each time you receive treatment or services at a FourCounty facility, or are seen by a FourCounty employee at another site, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

Understanding what is in your record and how your health information is used helps you to:
  1. Insure its accuracy,
  2. Better understand who, what, when, where, and why others may access your health information, and
  3. Make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of Four County Counseling Center, the information belongs to you and you have the right to:
  1. Request a restriction on certain uses and disclosures of your information including the right to restrict disclosure to your insurance provider about any services that you pay in full.
  2. Obtain a paper copy of the notice of privacy practices upon request.
  3. Inspect and copy your health record.
  4. Request corrections to your health record.
  5. Know who has been given information from your health record.
  6. Ask us to contact you at an alternate location or by an alternate method.
  7. Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
  8. To be notified of a breach of any unprotected/unencrypted health information.
Four County's Obligations
This organization is required to:
  1. Maintain the privacy of your health information.
  2. Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
  3. Abide by the terms of this notice.
  4. Notify you if we are unable to agree to a requested Restriction.
  5. Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. Such requests must be in writing and be sent to the Privacy Officer.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the Four County Privacy Officer at 574-722-5151 or 800-552-3106.

If you believe your privacy rights have been violated, you can register a complaint by calling the Four County Privacy Officer or the Office of Civil Rights at 312- 886-2359, 312-353-5693 (TDD) or 312 886-1807 (FAX). There will be no retaliation for filing a complaint.

Examples of how FOUR COUNTY may use your health information.

We will use your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from services at FourCounty.

We will use your health information for payment.
For example: A bill may be sent to you or a third-party payer. The information on the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations.
For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to improve the quality and effectiveness of the healthcare and service we provide.

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we re­quire the business associate to safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition.

Communication with Family: Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing: We may contact you to provide appointment reminders or in­formation about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising: We may contact you as part of a fund-raising effort.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena and a court order.

Other: Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Acknowledgement:
I acknowledge that on this date, I have received a copy of the Privacy Practices policy of Four County Counseling Center.

__________________________________________
Client or Personal Representative

_________________________________
Date signed

Effective date of this Notice: 9/20/2013

Client:
ID#:

Affiliated With

ASPIN FSSA hap The Joint Commission Logan Center for Autism Star Behavioral Health Providers National Health Service Corps