HIPAA Privacy Practices

The MCPST Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Practices Form describes legal use and disclosure of health information.

You can download a printable copy of the HIPAA Privacy Practices.

Please visit our MCPST Forms page for information about how to use this form if you are a new client.

USE AND DISCLOSURE OF HEALTH INFORMATION

Midwest Center for Psychotherapy and Sex Therapy may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations.  Provider has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment: Midwest Center for Psychotherapy and Sex Therapy may use your health information to provide care to you and disclose your health information to others who provide care to you.  For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.  Midwest Center for Psychotherapy and Sex Therapy may also disclose your health care information to individuals outside of the Midwest Center for Psychotherapy and Sex Therapy involved in your care including family members, pharmacists, or other health care professionals, with your written permission.

To Obtain Payment: Midwest Center for Psychotherapy and Sex Therapy may include your health information in invoices to collect payment from third parties for the care you may receive from Midwest Center for Psychotherapy and Sex Therapy.  For example, Midwest Center for Psychotherapy and Sex Therapy may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Midwest Center for Psychotherapy and Sex Therapy.  Midwest Center for Psychotherapy and Sex Therapy also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you.

To Conduct Health Care Operations: Midwest Center for Psychotherapy and Sex Therapy may use and disclose health information for its own operations in order to facilitate the function of Midwest Center for Psychotherapy and Sex Therapy and as necessary to provide quality care to all of Midwest Center for Psychotherapy and Sex Therapy’s clients.  Health care operations include activities such as:

-Quality assessment and improvement activities;

-Activities designed to improve health or reduce health care costs;

-Protocol development, case management and care coordination;

-Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment;

-Professional review and performance evaluation;

-Training programs including those in which students, trainees or practitioners in health care learn under supervision;

-Training of non-health care professionals;

-Accreditation, certification, licensing or credentialing activities;

-Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs;

-Business planning and development including cost management and planning related analyses and formulary development; and

-Business management and general administrative activities of Midwest Center for Psychotherapy and Sex Therapy.

For example, Midwest Center for Psychotherapy and Sex Therapy may use your health information to evaluate its staff performance, combine your health information with other Midwest Center for Psychotherapy and Sex Therapy clients in evaluating how to more effectively serve all of Midwest Center for Psychotherapy and Sex Therapy’s clients, disclose your health information to Midwest Center for Psychotherapy and Sex Therapy’s staff and contracted personnel for training purposes, and use your health information to contact you (unless you do not want to be contacted).

For Appointment Reminders: Midwest Center for Psychotherapy and Sex Therapy may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care with Midwest Center for Psychotherapy and Sex Therapy.

For Treatment Alternatives: Midwest Center for Psychotherapy and Sex Therapy may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

When Legally Required: Midwest Center for Psychotherapy and Sex Therapy will disclose your health information when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health: Midwest Center for Psychotherapy and Sex Therapy may disclose your health information for the following public activities and purposes:

-To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions;

-To report adverse events, product defects, to track products or enable product recalls and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration;

-To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease; and/or

-To an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence: Midwest Center for Psychotherapy and Sex Therapy is allowed to notify government authorities if Midwest Center for Psychotherapy and Sex Therapy believes a patient is the victim of abuse, neglect or domestic violence.  Midwest Center for Psychotherapy and Sex Therapy will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities: Midwest Center for Psychotherapy and Sex Therapy may disclose your health information to a health oversight agency for activities including:  audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action.  Midwest Center for Psychotherapy and Sex Therapy, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits.

In Conjunction with Judicial and Administrative Proceedings: As permitted or required by State law, Midwest Center for Psychotherapy and Sex Therapy may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Midwest Center for Psychotherapy and Sex Therapy makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes: As permitted or required by State Law, Midwest Center for Psychotherapy and Sex Therapy may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

To Coroners and Medical Examiners: Midwest Center for Psychotherapy and Sex Therapy may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors: Midwest Center for Psychotherapy and Sex Therapy may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements.  If necessary to carry out their duties, Midwest Center for Psychotherapy and Sex Therapy may disclose your health information prior to, and in reasonable anticipation of, your death.

In the Event of a Serious Threat to Health or Safety: Midwest Center for Psychotherapy and Sex Therapy may, consistent with applicable law and ethical standards of conduct, disclose your health information if Midwest Center for Psychotherapy and Sex Therapy, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions: In certain circumstances, the Federal regulations authorize Midwest Center for Psychotherapy and Sex Therapy to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation: Midwest Center for Psychotherapy and Sex Therapy may release your health information for worker’s compensation or similar programs, with client’s written permission if possible.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated above, Midwest Center for Psychotherapy and Sex Therapy will not disclose your health information other than with your written authorization.  If you or your representative authorizes Midwest Center for Psychotherapy and Sex Therapy to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

Right to Request Restrictions: You may request restrictions on certain uses and disclosures of your health information.  You have the right to request a limit on Midwest Center for Psychotherapy and Sex Therapy’s disclosure of your health information to someone who is involved in your care or the payment of your care.  However, Midwest Center for Psychotherapy and Sex Therapy is not required to agree to your request.  If you wish to make a request for restrictions, please contact the Privacy Official or your therapist at (608) 237-8000.

Right to Receive Confidential Communications: You have the right to request that Midwest Center for Psychotherapy and Sex Therapy communicate with you in a certain way.  For example, you may ask that Midwest Center for Psychotherapy and Sex Therapy only conduct communications pertaining to your health information with you privately with no other family members present.  If you wish to receive confidential communications, please contact the Privacy Official or your therapist at (608) 237-8000.

Right to Inspect and Copy Your Health Information: You have the right to inspect and copy your health information, including billing records.  A request to inspect and copy records containing your health information may be made to Privacy Official or your therapist at (608) 237-8000.  If you request a copy of your health information, Midwest Center for Psychotherapy and Sex Therapy may charge a reasonable fee for copying and assembling costs associated with your request.  You will be asked to make the request in writing and/or fill out an Authorization for Release of Information.

Right to Amend Your Health Information: You or your representative have the right to request that Midwest Center for Psychotherapy and Sex Therapy amend your records, if you believe your health information records are incorrect or incomplete.  That request may be made as long as the information is maintained by Midwest Center for Psychotherapy and Sex Therapy.  A request for an amendment of records must be made in writing to the Privacy Official or the client’s therapist at 6300 University Ave., Suite 125, Middleton, WI 53562.  Midwest Center for Psychotherapy and Sex Therapy may deny the request if it is not in writing or does not include a reason for the amendment.  The request also may be denied if your health information records were not created by Midwest Center for Psychotherapy and Sex Therapy, if the records you are requesting are not part of Midwest Center for Psychotherapy and Sex Therapy’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Midwest Center for Psychotherapy and Sex Therapy, the records containing your health information are accurate and complete.

Right to an Accounting: You or your representative have the right to request an accounting of disclosures of your health information made by Midwest Center for Psychotherapy and Sex Therapy for certain purposes authorized by law.  The request for an accounting must be made in writing to the Privacy Official or the client’s therapist at 6300 University Ave., Suite 125, Middleton, WI  53562. The request should specify the time period for the accounting starting on April 14, 2003.  Accounting requests may not be made for periods of time in excess of six (6) years.  Provider will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to a Paper Copy of this Notice: You or your representative has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously.  To obtain a separate paper copy, please contact Midwest Center for Psychotherapy and Sex Therapy at (608) 237-8000.

DUTIES OF MIDWEST CENTER FOR PSYCHOTHERAPY AND SEX THERAPY

Midwest Center for Psychotherapy and Sex Therapy is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices.  Midwest Center for Psychotherapy and Sex Therapy is required to abide by the terms of this Notice as may be amended from time to time. Midwest Center for Psychotherapy and Sex Therapy reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains.  If Midwest Center for Psychotherapy and Sex Therapy makes a material change to this Notice, Midwest Center for Psychotherapy and Sex Therapy will provide a copy of the revised Notice to you or your appointed representative.  You or your representative has the right to express complaints to Midwest Center for Psychotherapy and Sex Therapy and to the Secretary of Health and Human Services if you or your representative believes that your privacy rights have been violated.  Any complaints to Midwest Center for Psychotherapy and Sex Therapy should be made in writing to the Privacy Official or client’s therapist at 6300 University Ave., Suite 125, Middleton, WI 53562.  Midwest Center for Psychotherapy and Sex Therapy encourages you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

Midwest Center for Psychotherapy and Sex Therapy has designated the Privacy Official as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards.  You may contact this person at (608) 237-8000 or 6300 University Ave., Suite 125, Middleton, WI 53562.

EFFECTIVE DATE

This Notice is effective April 14, 2003.

IF YOU HAVE QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICIAL AT 6300 UNIVERSITY AVE., SUITE 125, MIDDLETON, WI  53562 OR (608) 237-8000.

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Midwest Center for Psychotherapy & Sex Therapy · 6300 University Avenue, Suite 125 · Middleton, WI 53562 · (P) 608-237-8000 · (F) 608-237-8005