Evan
M. Peterson, LCSW
Notice Of Privacy Practices
Revised: January 3, 2005
If you have any questions about this policy or
your rights contact Evan Peterson, LCSW, at 815-861-8800
or by mail to:
60 W. Terra Cotta Ave #101,
Crystal Lake, Illinois 60014.
USE
AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Evan Peterson, LCSW, respects your confidentiality
and will only release information about you according
to state and federal law. He will only use
minimum necessary information to accomplish any
task.
Information Within The Practice. In
order to effectively provide services, we will
share your information within the Practice. We
will use information to coordinate services, including
setting up your appointments and reviewing our
work. We may contact you to remind you of future
appointments and information about referrals and
treatment alternatives. We will not leave
messages on voicemail without your permission. Evan
Peterson, LCSW, will not send you e-mail unless
you specifically request that we send you email
to assist you with referrals to Work/Life resources.
Referrals Outside The Practice. We
will use or disclose information when necessary
to provide referrals to resources not related
to health care. With your consent, we will
use or disclose information when we make a referral
to others who provide services not offered by
the Practice and to assist you in finding potential
resources and coordinating benefits with your
insurance company.
Payments To Evan Peterson. Professional
services are paid for on a fee-for-service basis.
Evan Peterson will not contact your insurance
company to bill for services because he does not
accept insurance reimbursement.
Information Disclosed By Law. Under
state and federal law, information about you may
be disclosed without consent in these circumstances:
Emergencies: Sufficient information may be shared
to assist you in an emergency, which includes
if we believe you are a risk to yourself or others.
As Required by Law: We will provide
information as legally required by a subpoena,
court order, and as mandated by law, including
suspected child and elder abuse and neglect, and
with a coroner or medical examiner. We are
required to disclose information to a government
oversight agency for activities authorized by
law, such as audits and investigations.
Criminal Activity: If a crime
is committed on our premises or against our personnel
we may share information with law enforcement
to assist them in apprehending the criminal.
PATIENT
RIGHTS
Copy of Record. You may inspect
the record we have generated about you. We
may charge you a reasonable fee for copying and
mailing your record.
Release of Records. You may consent
in writing to release of your records to others. You
may revoke this consent at any time. You
may in a written request toEvan Peterson ask the
Practice not to use or disclose part of your information.
Amending Record. If you believe that something
in your record is incorrect or incomplete, you
may request we amend it. To do this contact Evan
Peterson and ask for the Request to Amend Health
Information form. In certain cases, we may file
a response to your statement and add that to your
record.
Accounting for Disclosures. You
may request an accounting of any disclosures we
have made related to your information, except
for information we used within the Practice, with
you, information that you gave us specific consent
to release, and information we are legally required
to release. To receive information regarding disclosures
made for a specific time period no longer than
six years after the last day of treatment, please
submit your request in writing to Evan Peterson
at the address above. We will notify you if there
is a cost for the report
.
Questions and Complaints. If
you have any questions, wish a copy of this Policy,
or have any complaints you may contact Evan Peterson
in writing at our office for further information.
You may complain to the Secretary of US Health
and Human Services if you believe your privacy
rights have been violated.
Changes To This Policy. Evan
Peterson may change this Privacy Policy in the
future based on the needs of the Practice and
changes in state and federal law.
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