NOTICE OF PRIVACY PRACTICES

This notice is in effect as of April 14, 2003.
THIS NOTE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Privacy Contact: If you have any questions about this policy or your rights, contact the Privacy Officer at United Cerebral Palsy of Greater Chicago, 160 North Wacker Drive, Chicago, IL 60606 312-368-0380
1. Statement of Our Duties

We are required by law to maintain the privacy of your Protected Health Information (PHI) and to provide you with this notice of our privacy practices and legal duties with respect to your PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to your PHI. We are required to provide this notice to you by the Health Insurance Portability and Accountability Act (‘HIPAA’). We are required to abide by the terms of this notice. We reserve the right to change the terms of this notice and to make any new provisions effective to all of the personal health information that we maintain about you. If we revise this notice, we will provide you with a revised notice by mail.

2. Use and Disclosure of Protected Information

In order to provide you care, there are times when we will need to share your PHI with others. This includes the following times, under federal law:

To carry out treatment functions. We may need to use or disclose your PHI without your permission for health care providers to provide you with treatment.

To carry out payment functions. We may use or disclose your PHI without your permission to carry out activities relating to billing, collection or payment or to receive third party payment. However, if state law is more restrictive, your PHI will be disclosed to a third person or for billing purposes only to the minimum extent necessary and in accordance with such state law.

To carry our healthcare operations. We may also use or disclose your PHI without your permission to carry out certain limited activities relating to your health insurance benefits, including conducting quality assessment activities.

3. Information Disclosed Without Your Consent

Under Federal Law, information can be disclosed without your consent in the following circumstances:

In an emergency, if you are not able to give or refuse permission, we will share information directly necessary for obtaining emergency medical care for you, in our professional judgment. To police or other authorities if we reasonably believe that disclosure is necessary to protect you or someone from a clear and immediate serious injury, disease or death. In response to a court order. As authorized by and the extent necessary to comply with worker’s compensation or other no-fault laws. To a health oversight agency for activities including audits or civil, criminal or administrative proceedings. To a public health authority for purpose of public health activities. To organ procurement organizations, or to other entities for approved research purposes. To a government authority, including a social service or protective services agency, authorized to receive reports of abuse, neglect or domestic violence.

4 Information Disclosed With Your Consent

All other uses of disclosures or PHI will be made only with you written permission. You may revoke your written consent at any time unless we have already acted in reliance upon it.

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

In certain limited circumstances, we may use or disclose your protected health information after we have given you an opportunity to object and you have not objected. For example, if you do not object, we may use limited information about you to maintain an office directory, to notify family members or any other person identified by you regarding issues directly related to such person’s involvement with your care or payment for that care, or in emergency circumstances.

5 Statement of Your Rights

This notice informs you of those uses and disclosures. There are certain uses and disclosures of or personal health information that we are permitted or required to make by law without your permssion. For all other uses and disclosures, we first must obtain your permission. In addition, you have the following rights:

The right to request that we place additional restrictions on our uses and disclosures of your personal health information. This request must be made in writing to the Privacy Contact. However, we are not obligated to agree to impose any such additional restrictions.

The right to access, inspect and copy the protected information pertaining to you that we maintain in our files about you.

The right to have us correct or amend any information that we create in error. Request to access or amend your health information should be send to the Privacy Officer at United Cerebral Palsy, 160 North Wacker Drive, Chicago, IL 60606. UCP Chicago may charge a reasonable fee for copying and mailing records.

The right to receive an accounting of the disclosures of your personal health information that we or a Business Associate make during the six year period prior to your request, for purposes other than activities related to your treatment, our payment functions or other health care operations and other exceptions specified in the Privacy Rule.

The right to request that you receive communications or personal health information in a confidential manner. For example, you may ask us to remind you of appointments by calling you at home instead of at work or by sending a message for your personal electronic mail instead of calling you. Your request must be made in writing to the Privacy Contact. United Cerebral Palsy is required to accommodate a reasonable request you make regarding such contact.

The right to obtain a paper copy of this notice from us upon request even if you have agreed to receive this notice electronically.

The right to request that we amend your mental health records by adding or deleting certain information that is incomplete or inaccurate. This request must be made in writing to the Privacy Contact. We may deny your request if we did not create the information you want changed, or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may then respond with a statement of disagreement that will be added to your records. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the amendment and to include the amendment in any future sharing of that information.

6 Information We Collect About You

We collect the following categories of information about you from the following sources:

Information that we obtain directly from you, in conversations or on applications or other forms that you fill out.

Information that we obtain as a result of our transactions with you.

Information that we obtain from your medical records and from medical professionals.

Information that we obtain from other entities, such as health care providers or other agencies, in order to provide services for you.

7 Complaints About Misuse of Health Information

You may complain either directly to us or to the Secretary of Health and Human Services if you believe that your rights with respect to our protection of your health information have been violated. To file a complaint with us, you may send a written statement to Privacy Officer at United Cerebral Palsy, 160 North Wacker Drive, Chicago, IL 60606. You will not be retaliated against in any way for filing a complaint.

8 Our Practices Regarding Confidentiality and Security

We respect client confidentiality and will only release information about you in accordance with applicable State and Federal Law. If state law is stricter, these more stringent provisions will always take precedence. This notice describes our policies related to use of mental health records.

We restrict access to nonpublic personal information about you to those employees who need to know that information in order to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices. In accordance with state and federal law, we will make reasonable efforts to limit use, disclosure of and requests for protected health information to the minimum necessary to accomplish the intended purpose.

This notice of Privacy Practices is effective as of April 14, 2003