Notice of Privacy Practices

Privacy Officer: Barbara C. DeLeone, MEd, CRC, PCC

How medical information about you may be used & disclosed & how you can get access to this information. Please review carefully:

You have the right to receive this notice in writing. You may also view it on Caritas Counseling website.

It is Caritas Counseling’s 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 health care is considered “Protected Health Information” (PHI). Caritas Counseling, LLC is required to extend certain protections to your PHI, and to provide this notice about Caritas Counseling privacy practices that explain how, when & why we may use or disclose you PHI. Except in specified circumstances, Caritas Counseling, LLC must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure. Caritas Counseling, LLC is required to follow these privacy practices; however, Caritas Counseling reserves the right to change privacy practices & the terms of this notice at any time.

How Caritas Counseling, LLC may use & disclose your protected health information (PHI):

Caritas Counseling, LLC uses & discloses PHI for a variety of reasons. Caritas Counseling has a limited right to use &/or disclose your PHI for purposes of treatment, payment & for health care operations. Beyond, Caritas Counseling must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If your PHI is disclosed to an outside entity I order for that entity to perform a function on Caritas Counseling’s behalf, Caritas Counseling must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that Caritas Counseling applies to your PHI. The law provides that Caritas Counseling, LLC is permitted to make some uses/disclosures without your consent or authorization. The following describes & provides examples of potential uses/disclosures of your PHI:

Treatment: Caritas Counseling, LLC may use or disclose your PHI to doctors, nurses & other health care personnel who are involved in providing your health care

Payment: Caritas Counseling, LLC may use/disclose your PHI in order to bill & collect payment for your health care services, including contacting your private insurer for payment for services rendered.

Health Care Operations: Caritas Counseling, LLC may disclose your PHI to evaluate the quality of services provided by your therapist.

Appointment reminders: Caritas Counseling may call & leave appointment message reminders unless Caritas Counseling is provided alternative instructions.

Use & Disclosures of PHI Requiring Authorization:

For uses & disclosures beyond treatment, payment & health care operations purposes Caritas Counseling, LLC is required to have written authorization, unless the use or disclosure is included in one of the exceptions described below. Authorizations can be revoked, in writing, at any time to stop future uses/disclosures except to the extent that Caritas Counseling has already undertaken an action in reliance upon your authorization.

Uses & Disclosures of PHI from Mental Health Records not Requiring Consent or Authorization:

The law provides that Caritas Counseling, LLC may use/disclose your PHI from mental health records without consent or authorization in the following circumstances:

When required by law: PHI may be disclosed when a law requires that Caritas Counseling report information about suspected abuse, neglect or relating to suspected criminal activity, or in response to a court order. Caritas Counseling, LLC must also disclose PHI to authorities that monitor compliance with these privacy requirements.

For health oversight activities: Caritas Counseling, LLC may disclose PHI to a protection & advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.

Relating to descendents: Caritas Counseling, LLC may disclose PHI related to a death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye or tissue donations or transplants.

To avert threat to health or safety: In order to avoid a serious threat to health or safety, Caritas Counseling, LLC may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

For research purpose: In certain circumstances & under supervision of a privacy board, Caritas Counseling, LLC may disclose PHI to assist mental health research

For specific government functions: Caritas Counseling may disclose PHI of military personnel & veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility & enrollment & for national security reasons, such as protection of the President.

Your Rights Regarding Your Protected Health Information:

To request restrictions on uses/disclosures: You have the right to ask that Caritas Counseling, LLC limit how your PHI is used or disclosed. Your request will be considered, but Caritas Counseling is not legally bound to agree to the restriction. To the extent that Caritas Counseling agrees to any restrictions on use/disclosure of your PHI, Caritas Counseling will put the agreement in writing and abide by it except in emergency situations. Caritas Counseling, LLC cannot agree to limit uses/disclosures that are required by law.

To choose how Caritas Counseling contacts you: You have the right to ask that Caritas Counseling send you information at an alternative address or by alternative means. Caritas Counseling must agree to your request as long as it is reasonably easy to do so.
To inspect & request a copy of your PHI: You have a right to see your PHI upon your written request. Caritas Counseling, LLC will respond to your request within 30 days. If you want copies of you PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied & to have prior information of the cost of copying.

To request amendment of your PHI: If you believe that there is a mistake or missing information in Caritas Counseling record of your PHI, you may request, in writing, that Caritas Counseling, LLC correct or add to the record. Caritas Counseling will respond within 60 days of receiving your request. Your request may be denied if it is determined that the PHI is correct & complete, not part of Caritas Counseling records, or not permitted to be disclosed. Any denial will state the reasons for denial & explain your rights to have the request & denial, along with any statement in response that you provide, appended to your PHI. If the request is approved, the PHI will be changed, you will be informed as well as any relevant others.

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, except on instances of disclosure for treatment, payment, and health care operations. The list also will not include any disclosures made to law enforcement officials or disclosures make prior to 4/14/03. Caritas Counseling, LLC 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 6 years from the effective date. There is no charge for up to one such list each year, but there may be a charge for more frequent requests.

How to Complain About Caritas Counseling, LLC Privacy Practices:

If you think your privacy rights have been violated or you disagree with a decision made regarding access to your PHI, you may file a complaint with the person listed below. You may also file a written complaint with the Secretary of the U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Washington, DC, 20201 or call 1.877.696.6775. No retaliatory action will be taken against you if you make such complaints.

Contact Person for Information or to Submit a Complaint: If you have questions about this Notice or any complaints about Caritas Counseling, LLC privacy practices, please contact the Privacy Officer at:

338 Northeast Ave., Ste. K, Tallmadge, OH 44278, phone 330.630.3210.

6/1/07