This Notice will tell you how we handle your Protected Health Information (PHI). It tells how we use this information in this office, how we share it with other professionals and

organizations and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family. Because the laws of this state and the laws of the federal government are very complicated and we don’t want to make you read a lot that may not apply to you, we have not included the entire documents. If you have any questions or want to know more about anything in this Notice, please ask our Privacy Officer for a more detailed explanation or to view a copy of these laws or codes.

Each time you visit us or any doctor’s office, hospital, clinic, or many other agencies, known as ‘healthcare providers,’ information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or tests and treatment you received from us or from others, or about payment for healthcare. The information we collect from you is called, in the law, Protected Health Information (PHI). This information goes into your record or file at Oak Lawn Family Service.

In this office this Protected Health Information (PHI) is likely to include these kinds of information:

. Your history: As a child, in school, work, marriage and personal history.

. Reasons you came for treatment: Your problems, complaints, symptoms or needs.

. Diagnoses: Diagnoses are the medical terms for your problems or symptoms.

. A Treatment Plan: A list of treatments and any other services which we think will be best to help you.

. Case and/or Progress Notes: Each time you come in, we write down some things about how you are doing, what we notice about you and what you tell us.

. Records we get from others who treated or evaluated you.

. Psychological test scores, school records and other reports.

. Information about medications you took or are taking.

. Legal matters.

. Billing and insurance information.

This list is just to give you an idea and there may be other kinds of information that go into your record or file here.

We use this information for many purposes. For example, we may use it:

. To plan your care and treatment;

. To decide how well our treatments are working for you;

. When we talk with other healthcare professionals, who are also treating you such as your family doctor, primary care physician or the professional who referred you to us;

. To show that you actually received the services from us which we billed to you or to your health insurance company;

. For teaching and training other healthcare professionals;

. For medical and psychological research;

. For public health officials trying to improve health care in this area of the country;

. To improve the way we do our job by measuring the results of our work.

When you understand what is in your record and what it is used for, you can make better decisions about who, when and why others should have this information.

Although your record or file is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can read it and/or request a copy of it, (but we may charge you for the costs of copying and mailing, if you want it mailed to you). In some very rare situations, you cannot view all of what is in your records. If you find anything in your records that you think is incorrect or believe something important is missing, you can ask us to amend (add information to) your record, although in some rare situations we don’t have to agree to do that. If you want, our Privacy Officer can explain more about this.

We are also required to tell you about privacy because of the Privacy Regulations of a Federal Law, specifically the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA requires us to keep your Protected Health Information (PHI) private and to give you a notice of our legal duties and privacy practices, which is called the “Notice of Privacy Policy” (NPP). We will obey the rules of this notice as long as it is in effect. If we change the Notice of Privacy Policy (NPP), we will post the new Notice in our office where

everyone can see. You or anyone else can obtain a copy from our Privacy Officer at any time.

When your information is read by someone in this office, the law refers to this as ‘use’. If the information is shared with or sent to others outside this office that is referred to in the law as ‘disclosure’. Except in some special circumstances, when we use your Protected Health Information (PHI) here or disclose it to others, we share only the minimum necessary Protected Health Information (PHI) needed for those other people to do their jobs. The law gives you rights to know about your Protected Health Information (PHI), how it is used and how it is disclosed (shared). Oak Lawn Family Service uses and discloses Protected Health Information (PHI) for several reasons. Primarily, we use and disclose Protected Health Information (PHI) for routine purposes needed to operate this Agency. We will inform you if there are any nonroutine uses or requests for your  protected Health Information (PHI). At that time, you will be

asked to sign a special Authorization Form allowing release of your Protected Health Information (PHI), we will only disclose the minimum necessary to satisfy the request. There are special circumstances where, by law, we can use and disclose your Protected Health

Information (PHI), we will explain this in more detail below.

After you have read this Notice or the Short Form Brochure, you will be asked to sign a separate Receipt and Acknowledgment of Notice Form to allow us to use and

share your Protected Health Information (PHI). However, if you refuse or you fail to acknowledge receipt but we make a good faith effort to obtain a written acknowledgment (which we document along with the reasons for the failure), we are

permitted by law to use or disclose your Protected Health Information (PHI) with other people or organizations to provide Treatment to you, arrange for Payment for our

services, or some other business functions called Health Care Operations. Together these routine purposes are called TPO and with or without your acknowledgment, the law allows us to use and disclose your Protected Health Information (PHI) for TPO. Take a minute to reread that last sentence until it is clear because it is very important.

Next, we will tell you more about TPO.

We need information about you and your condition to provide care to you. When you come to see us, several people in our office may collect information about you and all of it may go into your record or file here. Generally, we may use or disclose your Protected Health Information (PHI) for three purposes:

Treatment, obtaining Payment and what are called Health Care Operations.

Let’s see what these mean.

We use your medical information to provide you with psychological treatments or services. These might include individual, couple, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or

measuring the benefits of our services.

We may share or disclose your Protected Health Information (PHI) to others who provide treatment to you. We are likely to share your information with your personal Physician as Illinois law requires. If you are being treated by a team,

we can share some of your Protected Health Information (PHI) with them so that all the services you receive work together effectively. The other professionals treating you may also enter their findings, actions taken and goals into your record or file. This information is necessary to decide what

treatments work best for you and develop a Treatment Plan. We may refer you to other professionals or consultants for services we cannot provide. When we do this, we need to tell them some things about you and your conditions. We will get back their findings and opinions and those will go into your records here. If you receive treatment in the future from other professionals, we can also share your Protected Health Information (PHI) with them. These are some examples, so that you can see how we use and disclose your Protected Health Information (PHI) for treatment.
For Payment

We may use your information to bill you, your insurance, or others so we can be paid for the treatments we provide to you. We may contact your insurance company to check on exactly what your insurance covers. We may have to tell

them about your diagnoses, what treatments you have received and the changes we expect in your conditions. We will need to tell them about when we met, your progress and other similar things.

For Health Care Operations

There are a few other ways we may use or disclose your Protected Health Information (PHI) for what are called Health Care Operations. For example, we may use your Protected Health Information (PHI) to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study disorders and treatments and make plans for services that are needed. If we do, your name and personal information will be removed from what we send.

b Other Uses and Disclosures in Health Care

Appointment Reminders
We may use and disclose Protected Health Information (PHI) to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or your work or prefer some other way to reach you, we usually can arrange that. Just tell us.

Treatment Alternatives
We may use and disclose your Protected Health Information (PHI) to tell you about or recommend possible treatments or alternatives that may be of help to you.

Other Benefits and Services
We may use and disclose your Protected

Health Information (PHI) to tell you about health-related benefits or services that may be of interest to you.

Research
We may use or share your information to do research to improve treatments. For example, we may compare two treatments for the same disorder to see which works better or faster or costs less. In all cases, your name, address and other personal information will be removed from the information given to researchers. If they need to know who you are, we will discuss the research project with you and you will have to sign a special Authorization Form before any information is shared.

Business Associates
There are some jobs we may hire other businesses to

do for us though we are not doing so at the present time. In the law, they are called our Business Associates. Examples, include a copy service we may use to make copies of your records or files and a billing service who would figure out, print and mail our bills. These business associates need to receive some of your Protected Health Information (PHI) to do their jobs properly. To protect your privacy, they will agree in a contract with us to safeguard your information.

2 Uses and Disclosures that Require Your Authorization

If we want to use your information for any purpose besides Treatment, Payment or Health Care Operations (TPO) or those we described above, we need your permission on an Authorization Form. We don’t expect to need this very often.

If you do authorize us to use and disclose your Protected Health Information (PHI), you can revoke (cancel) that permission, in writing, at any time. After that time, we will not use or disclose your information for the purposes that we agreed to. Of course, we cannot take back any information we had disclosed with your permission or that we had used in our office.

3 Uses and Disclosures that Don’t Require Your Consent or Authorization

The laws let us use and disclose some of your Protected Health Information (PHI) without your consent or uthorization in some cases. Here are examples of when we might have to share your information:

When Required by Law -

There are some federal, state or local laws which require us to disclose Protected Health Information (PHI).

• We have to report suspected child abuse.

• If you are involved in a lawsuit or legal proceeding and we receive a subpoena, discovery request or other lawful process, we may have to release some of your Protected Health Information (PHI). We will only do so after trying to tell you about the request, consulting your lawyer or trying to get a court order to protect the information they requested.

• We have to disclose some information to the government agencies which check on us to see that we are obeying the privacy laws.

For Law Enforcement Purposes

We may release Protected Health Information (PHI) if asked to do so by a law enforcement official to investigate a crime or criminal.

For Public Health Activities

We might disclose some of your Protected Health Information (PHI) to agencies which investigate diseases or injuries.

Relating to Decedents

We might disclose Protected Health Information (PHI) to coroners or medical examiners in the event of your death.

For Specific Government Functions

We may disclose Protected Health Information (PHI) of military personnel and veterans to government benefit programs relating to eligibility and enrollment. We

may disclose your Protected Health Information (PHI) to Workers Compensation and Disability programs, or to correctional facilities, if you are an inmate and for National Security reasons.

To Prevent a Serious Threat to Health or Safety

If we come to believe that there is a serious threat to your health or safety or that of another person or the public, we can disclose some of your Protected Health Information (PHI). We will only do this to persons who can prevent the danger.

4 Uses and Disclosures Where You Have an Opportunity to Object
We can share some information about you with your family or close others. We will only share information with those involved in your care and anyone else you choose such as close friends or clergy. We will ask you about whom you want us to tell certain information about your condition or treatment. You can tell us what you want and we will honor your wishes as long as it is not against the law. If it is an emergency - so we cannot ask if you disagree - we can share information if we believe that it is what you would have wanted and if we believe it will help you if we do share it. If we do share information, in an emergency, we will tell you as soon as we can. If you don’t approve, we will stop as long as it is not against the law.

5 An Accounting of Disclosures We Have Made

When we disclose your Protected Health Information (PHI) we may keep some records of whom we sent it to, when we sent it and what we sent. You can request an accounting (a list) of many of these disclosures.

E If You Have Questions or Problems

If you need more information or have questions about the Privacy Practices described above, please speak to the Privacy Officer at the telephone number listed below.

If you have a problem with how your Protected Health Information (PHI) has been handled or if you believe your privacy rights have been violated, contact the Privacy Officer. You have the right to file a complaint with us and/or with the Department of Health and Human Services - Office for Civil Rights at the following address:

Office for Civil Rights
U.S. Department of Health and Human Services

233 North Michigan Avenue, Suite 240

Chicago, IL 60601

All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way.

The effective date of this notice is September , 2007.