Effective Date: January 2015

Child’s Play Behavior Analysis

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Notice of Privacy Practices

This Notice Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information.

Please Review It Carefully. 

Our Responsibilities

Child’s Play Behavior Analysis takes the privacy of your health information seriously.

We understand the importance and sensitivity of your health information. We are required by law to maintain your privacy and to provide you with this Notice of Privacy Practices (“Notices”). We are required to abide by the terms of the notice that is currently in effect.

How We May Use and Disclose Your Health Information

We protect the privacy of your health information because it is the right thing to do. We use your health information (and allow others to have it) only as permitted by federal and state laws. When we care for you, we gather and create some of your health information. This Notice includes examples in each category below of how we will use and share your information. Not every use or disclosure is listed below; however, all permissible uses and disclosures will fall within one of the categories.

  • For Treatment: We use information about you to understand your health condition and to treat you when you are sick. We may share your health information with doctors, nurses, aids, technicians or other staff who are involved in taking care of you. We might use your health information to manage or coordinate your treatment health care or other related services. We might share your medical information with your physician or other health care provider who is providing treatment to you. Whether or not we are involved with your treatment at the time. For example, a doctor treating you for a broken leg may need to know if you have diabetes because if you do, this may impact your recovery. We may receive and share prescription information to help you avoid harmful drug interactions. Different departments of the facility may also share health information about you in order to coordinate different things you might need such as medications, x-rays, laboratory work, etc…
  • For Payment: To receive payment for our services, we may send your health information to an insurance company or other third party.  We may send your health medical information to another health care provider or payer of health care for their own payment activities.  For example, your insurance company may request information about your treatment plan or progress graphs and we must provide that information to obtain payment.
  • For Health Care Operations: We may use and disclose your health information to enable Child’s Play Behavior Analysis to make sure you receive competent, quality health care, and to maintain and improve the quality of health care we provide.  We may assess the care and outcomes in your case and others like it and then use the results to continually improve the quality of care for all patients we serve.  For example, we may combine health information about many patients to evaluate the need for new services or treatment.  We may combine health information we have with that of other facilities to see where we can make improvements.

The law sometimes requires us to share information for specific purposes, including reporting to:

  • The Department of Health to report communicable diseases, traumatic injuries.
  • Public health authorities to report child abuse or suspected child abuse, if authorized or otherwise required reporting by law.
  • Law enforcement official if required to do so by law, for example, to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.
  • Governmental inspectors who, for example, make sure our facilities are safe.
  • Court officers, as required by law, in response to a court order or a valid subpoena.
  • Governmental authorities to prevent serious threats to the public’s health or safety.
  • Governmental agencies and other affected parties, to report a breach of health information privacy or in the case of a compliance review to determine whether we are complying with privacy laws.
  • To a worker’s compensation program if a person is injured at work and claims benefits under that program.
  • To business associates or third parties that we have contracted with to perform agreed upon services.

Additional Information 

  • Individual involved in your care or payment for your care: We may release health information about you to a family member, or any other person identified by you who is involved in your health care or helps pay for your care. We may also disclose health information about you to notify your family or an emergency contact that you are Child’s Play Behavior Analysis or to an entity assisting in a disaster relief effort so that your family can be notified about you and your location.
  • Disclosures to You: Upon a request by you, we may use or disclose your medical information in accordance with your request. We may contact you to remind you about appoints and tell you about possible treatment alternatives or health-related benefits or services.
  • Incidental Uses and Disclosures: Upon a request by you, we may use or disclose your medical information. For example, while we have safeguards in place to protect against others overhearing our conversation. Please be assured, however that we have appropriate safeguards in place to avoid these types of situations, and others, as much as possible.
  • Disclosures by Members of Our Workforce: Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member’s belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, worker or the public. In addition, if a workforce member is a crime victim that you are involved with, the member may disclose your personal information to law enforcement official to report the crime.
  • Research: Under certain circumstances, we may use and disclose health information about you for research purposes. All research projects are subject to a special approval process and information released is only done so with your consent or with appropriate authority as permitted by law. We may share medical information about you with people preparing to conduct a research project. For example, we may share information to help them look for patients with specific medical needs. We will not allow the preparatory researchers to remove your information from our faculty.
  • Psychotherapy Notes: If applicable, we must obtain your written authorization before we may use or disclose your psychotherapy notes, except for; use by the originator of the psychotherapy not for treatment; use or disclosure by Child’s Play Behavior Analysis to its own mental health training programs; or use for disclosure by Child’s Play Behavior Analysis to defend itself in a legal action or other proceeding brought by the individual.
  • Marketing: We must obtain your written authorization before we may use or disclose your health information for marketing purposes, except for face-to-face communication made by us to you or a promotional gift of nominal value provided by us to you. You may opt out of receiving such communications by following the opt-out instructions on the communication you receive.
  • Authorization Required: Child’s Play Behavior Analysis does not engage in selling your health information; however if we do, we must obtain your written authorization before we may sell your health information. Other uses and disclosures not described in this Notice will be made only with authorization from you or your personal representative.

Breach Notification

We are required to notify you in the event of a breach of your unsecured protected health information, and will do so.

Your Rights Regarding Your Health Information

You have the following rights regarding health information we maintain about you:

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. You have the right to restrict disclosures of your health information to your health plan for payment and health care operation purposes (and not for treatment) if the disclosure pertains to a health care item or service for which you paid out-of-pocket in full. If requesting a restriction for a health care item or service for which you paid out-of-pocket in full. If requesting a restriction for a health care item or service for which you paid out-of-pocket in full, we will honor your request, unless the disclosure is necessary for your treatment or is required by law. For all other restriction requests, We are not required to agree to your request. If you do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Who This Notice Applies To: This notice describes Child’s Play Behavior Analysis practices and those of:

  • Any health care professional authorized to enter information into or consult your medical record or who provides treatment to you while you are at or in the facility, staff members of such and any other health care provider that is involved in your care at the facility.
  • All location departments of Child’s Play Behavior Analysis
  • Any member of a volunteer group we allow to help you
  • All employees, staff and other Child’s Play Behavior Analysis personnel at the facility.

All of these entities, site and locations follow the terms of this notice while providing services at our facility. In addition, these entities, sites, and locations may share health information with each other for treatment, payment or operations purposes described in this notice.

Changes To This Notice: We reserve the right to change this notice. We reserve the right to make the revised notice effective for health information we already have about you, as well as any information we receive in the future. The notice will be posted in our facility and on our website and include the effective date. The notice is also available to you upon request. In addition, if we revise the notice, you may request a copy of the notice currently in effect.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with Child’s Play Behavior Analysis or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact Jason Shaw or Rebecca Fulcher at the location below. All complaints must be in written form.

You will not be penalized, discriminated against, retaliated against, or intimidated for filing a complaint.

If you have any questions about this notice, please contact:

Child’s Play Behavior Analysis

4118 N. Clinton St, Fort Wayne, IN 46805

P (260) 373-1050

F (260) 471-0285