Evan M. Peterson Professional Services
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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:
evanmpeterson, LLC
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 email 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 to Evan 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.