SUSAN F. WALSH, PH.D. LTD.
NOTICE OF PRIVACY PRACTICES
FOR
SCIENTIFIC RECOVERY PATIENTS

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

SUMMARY OF YOUR PRIVACY RIGHTS

Susan F. Walsh, Ph.D. is committed to preserving the privacy and confidentiality of your health information whether created by me or maintained on my premises. I am required by certain federal and state regulations to implement policies and procedures to safeguard the privacy of your health information. Copies of my privacy policies and procedures are maintained in my office. I am required by state and federal regulations to abide by the privacy practices described in this notice including any future revisions that I may make to the notice as may become necessary or as authorized by law.

Individually identifiable information about the provision of health care services to you, your past, present, or future health or condition, or payment for the health care treatment or services you receive is considered protected health information. As such, I am required to provide you with this Privacy Notice that contains information regarding my privacy practices that explains how, when and why I may use or disclose your protected health information as well as your rights and my obligations regarding any such uses or disclosures. Except in specified circumstances, I will use or disclose only the minimum necessary protected health information necessary to accomplish the intended purpose of the use or disclosure.

I have a limited right to use and disclose your health information for purposes of your treatment or for the operations of my practice. For other purposes, you must give me your written authorization to release your protected health information unless the law permits or requires me to make the use or disclosure without your authorization.

UNDERSTANDING YOUR HEALTH RECORD & INFORMATION

When you enroll for Scientific Recovery services provided by Susan F. Walsh, Ph.D., Ltd., a record of personal health information is created. As you progress through your treatment services, this record is updated. This information, often referred to as your health record, serves as a:

• Plan for your care and treatment
• Communication source between the health care professionals providing your care
• Tool with which I can review results and continually work to improve the care I provide
• Means by which private insurance payers can verify the services billed
• Legal document that describes the services you receive.

YOUR PRIVACY RIGHTS

Although your health record is the physical property of Susan F. Walsh, Ph.D., Ltd., the information belongs to you. You have the right to:

Inspect and receive a copy of your health record. You have the right to inspect and copy your health information contained in your health record. In order to inspect or copy your health information, you must submit a written request. If you request a copy of your health information, you may be charged a reasonable fee for the paper, labor, mailing, and other costs involved in filling your request.

Request a restriction on certain uses and disclosures of your health information. You have the right to request that I limit how I use or disclose your protected health information for treatment, payment, or health care operations. For example, you have the right to request a limit on the health information I disclose about you to a family member who may be assisting you with the payment for your services.

Request a correction/amendment to your health record if you believe the health information I have about you is incorrect or incomplete. You have the right to make such a request of me as long as I maintain/retain your health record. I will respond within sixty (60) days of receipt of your written request. I may deny your request if: a) your request is not submitted in writing; b) your written request does not contain a reason to support your request; c) it is not part of the health information kept by me; or d) the information is already accurate and complete. If your request is denied, I will provide you with a written notification of the reason(s) for such denial and your rights to have the request, the denial, and any written response you may have relative to the information and denial process appended to your health record.

Request confidential communication about your health information. You may ask that I communicate with you at a location(s) and by means of communication of your choice. To request confidential communications you must: a) notify me in writing; b) indicate the information you wish to limit; c) indicate the location and specific means of communication you wish me to use when communicating with you. An opportunity to make these requests will be provided to you at Intake.

Request a listing of certain disclosures Susan F. Walsh, Ph.D. has made of your health information. This information is maintained for six (6) years or the life of the record, whichever is longer. You have the right to request that I provide you with a listing of when, to whom, for what purpose, and what content of your protected health information I have released over the specified period of time. This accounting will not include any information I have released for the purposes of treatment, payment, or health care operations, information released to you, or any releases pursuant to your authorization. Your request may not include releases prior to May 1, 2006. I will respond to your request within sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be notified of such extension. However, in no case will such extension exceed thirty (30) days.

Revoke your written authorization to use or disclose health information.This does not apply to health information already disclosed or used in circumstances where I have taken action on your authorization or the authorization was obtained as a condition of your obtaining insurance reimbursement and the insurer has a legal right to the information under the policy or the legal right to contest a claim under the policy.

Obtain a copy of the Susan F. Walsh, Ph.D., Ltd. Notice of Privacy Practices for Scientific Recovery Patients. A copy of this notice will be provided to you at Intake.

SUSAN F. WALSH PH.D. LTD. RESPONSIBILITIES

Susan F. Walsh, Ph.D. is required by law to:

• Maintain the privacy of your health information.
• Inform you about my privacy practices regarding your health information.
• Notify you if I am unable to agree to a requested restriction.
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
• Honor the terms of this notice or any subsequent revisions of this notice.

Susan F. Walsh, Ph.D., Ltd. reserves the right to change its privacy practices and to make the new provisions effective for all protected health information it maintains. If Susan F. Walsh, Ph.D., Ltd. makes any significant changes to this Notice, the revised Notice of Privacy Practices for Scientific Recovery Patients will be posted in the office and on its web site at www.scientificrecovery.com. You may also request a paper copy of the revised notice.

Susan F. Walsh, Ph.D. understands that health information about you is personal and is committed to protecting your health information. Susan F. Walsh, Ph.D.will not use or disclose your health information without your permission, except as described in this Notice or as permitted by the Privacy Act.

HOW SUSAN F. WALSH PH.D. LTD. 
WILL USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

Susan F. Walsh, Ph.D. may use and disclose your health information to facilitate your treatment by other health professionals involved in your Scientific Recovery care.  For example: Your personal health information will be recorded in your health record and used to determine the course of treatment for you. Before you see the physician who will provide medication management services to you, I may disclose your relevant health information to that physician for treatment purposes only.

At your request, Susan F. Walsh, Ph.D. may use and disclose your health information to assist you in applying to your health insurance provider for reimbursement of costs for your Scientific Recovery services.  For example: If you request that I complete insurance forms so that you can apply for reimbursement from your insurance provider, I will provide you with a paid bill to send to your health plan. The information accompanying the paid bill will include information that identifies you as well as your diagnosis and the treatment services provided to you by me.

Susan F. Walsh, Ph.D. may use and disclose health information for health care operations.  For example: Susan F. Walsh, Ph.D. may use your health information to evaluate your care and outcomes. This information will be used to continually improve the quality and effectiveness of the services provided.

Uses and Disclosures about Decedents: Susan F. Walsh, Ph.D. may use or disclose health information about decedents to a coroner or medical examiner for the purpose of identifying a deceased person, determining the cause of death, or other duties as required by law.

Workers Compensation: Susan F. Walsh, Ph.D. may use or disclose health information for Workers’ Compensation purposes as required by law.

Child Abuse/Neglect: Susan F. Walsh, Ph.D. is a mandated reporter required by law to report cases of suspected child abuse and/or neglect to government agencies authorized by law to receive such reports. Such reports may require the use or disclosure of limited protected health information.

Compelling Circumstances:  Susan F. Walsh, Ph.D. may use or disclose health information in certain situations that involve compelling circumstances affecting the health or safety of an individual. For example, in certain circumstances: (1) Susan F. Walsh, Ph.D. may use or disclose protected health information about you if necessary to prevent or lessen a serious or imminent threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat. (2) As required by law, Susan F. Walsh, Ph.D. may use or disclose protected health information to report a crime committed on office premises; and (3) Susan F. Walsh, Ph.D. may make other disclosures of protected health information that are authorized or required by law.

Non-Violation of this Notice: Susan F. Walsh, Ph.D. is not in violation of this Notice if protected health information is disclosed under the following circumstances: 1) In response to a complaint filed with the Illinois Department of Financial and Professional Regulation; 2) In response to a request for professional review by the National Association of Social Workers for grievances pertaining to professional conduct.

Any other uses and disclosures will be made only with your written authorization, which you may later revoke in writing at any time. Such revocation would not apply where the health information already has been disclosed or used or in circumstances where Susan F. Walsh, Ph.D. has taken action in reliance on your authorization or the authorization was obtained as a condition of obtaining insurance reimbursement and the insurer has a legal right to the information under the policy or the legal right to contest a claim under the policy.