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NOTE: 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.

Lutheran Social Services of Illinois is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice, or if you want more information about the privacy practices at Lutheran Social Services of Illinois, please contact the office of the:

Privacy Official
c/o Lutheran Social Services of Illinois
1001 E. Touhy Avenue, Ste. 50
DesPlaines, Illinois 60018
Tele: 847.635.4600
Effective date of this notice: April 14, 2003

How Lutheran Social Services of Illinois May Use or Disclose Your Health Information

Lutheran Social Services of Illinois (LSSI) collects health information from you and stores it in a chart and/or on a computer. This is your medical record. The medical record is the property of LSSI, but the information in the medical record belongs to you. LSSI protects the privacy of your health information. The HIPAA law permits LSSI to use or disclose your health information for the following purposes:

1. Treatment

Treatment means the provision, coordination or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a client/patient; or the referral of a client/patient for health care from one health care provider to another.

Use or disclosure of your health care information for the purposes of providing you with treatment DOES NOT REQUIRE THAT WE OBTAIN YOUR AUTHORIZATION OR CONSENT.

Here’s an example of a use or disclosure for treatment purposes:

Mr. New Client telephones Central Intake after hearing a radio public announcement. Mr. New Client asks for and receives an appointment for an assessment. Mr. New Client provides the intake worker with personal information, including his name, address, telephone number, date of birth and specific information regarding his symptoms, which he describes to include restlessness, insomnia and erratic thought patterns. Mr. New Client asks to see a counselor and informs the intake worker that he once saw a clinical psychologist for a depressive disorder. Mr. New Client provides the name, address and telephone number of his former psychologist. The LSSI assessor contacts Mr. New Client’s medical doctor and former clinical psychologist for information pertaining to treating Mr. New Client’s current presenting condition.

The detailed and confidential information necessary to fully assess Mr. New Client is gleaned from him during a formal assessment. Under the revised Privacy rules (August 14, 2002), LSSI is not required to obtain a written consent or authorization from Mr. New Client to obtain his records from both his medical physician and his former clinical psychologist. The August 14, 2002, rules permit an exchange of information between LSSI and the former medical doctor and clinical psychologist without having a written authorization or consent providing that the minimum necessary information is exchanged solely for the purposes of treating Mr. New Client.

Under these Privacy rules (August 14, 2002), the assessor uses information from his comprehensive assessment, the records of Mr. New Client’s physical condition as supplied by his medical doctor and clinical psychologist (who supplied the minimum necessary protected health information) to develop a thorough clinical picture of Mr. New Client’s current needs. The assessor reviews his assessment and treatment recommendations with his supervisor before meeting again with Mr. New Client to address the recommendations and commencing treatment.

2. Payment

Payment means the activities undertaken by Lutheran Social Services of Illinois (LSSI) to obtain or provide reimbursement for the provision of health care or social services and the activities undertaken on behalf of the individual receiving health care or social services from LSSI to determine eligibility or insurance coverage, billing, claims management, collection activities or obtaining payment under a contract for reinsurance. These activities include, too, a review of health care services with respect to medical necessity, coverage under a health plan and appropriateness of care. These activities may include, furthermore, utilization review activities, precertification and preauthorization services, concurrent and retrospective reviews of services. The activities may require disclosure to consumer reporting agencies of specific protected health information relating to the collection of premiums or reimbursement such as: name and address; date of birth; Social Security Number; payment history; account number; and name and address of health care provider and/or health plan.

Here’s an example of a use or disclosure for payment purposes:

Mr. New Client provided the intake worker with a copy of his health plan card. Lutheran Social Services of Illinois contacts Mr. New Client’s health plan to verify his coverage and receives authorization from the plan to provide Mr. New Client with 12 weeks of individual psychological counseling services by a trained master’s-level therapist (supervised by a clinical psychologist).

3. Regular Health Care Operations

Regular health care operations at Lutheran Social Services of Illinois (LSSI) include the following:

Conducting quality assessment and improvement activities;

Reviewing the quality and competence of health care professionals; conducting training so that practitioners may, under supervision, improve their skills, and for certification, licensing or credentialing purposes;

Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance;

Business planning and development, such as conducting cost-management and planning-related analyses to managing and operating the agency; and

General administrative activities, such as compliance with the requirements of the HIPAA of 1996, client satisfaction, resolution of internal grievances and, consistent with 164.514, creating de-identified health information, fundraising for the benefit of LSSI, and marketing for which an individual authorization is not required.

Here is an example of a use or disclosures for health care operations purposes:

Mr. New Client, for the purposes of LSSI internal quality assessment and improvement purposes, and for the purposes of meeting the requirements of the Council On Accreditation, provides the agency with demographic information, including his: name, address, city, state, ZIP code, Social Security Number, sex, age-group, yearly income and ethnicity, which are included in a database from which LSSI draws non-specific characteristics of the clients it serves.

This demographic information is entered into the agency’s database to develop a profile of the characteristics of the populations being served by the agency and is matched with census statistics to determine whether the agency is adequately serving all identified sub-groups within its service areas.

4. Information provided to you

Lutheran Social Services of Illinois (LSSI) provides access to individuals to inspect and obtain a copy of protected health information about the individual except as follows: psychotherapy notes; information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding; protected health information that is subject to CLIA of 1988 as may be prohibited by law or exempt from the CLIA of 1988 pursuant to 42CFR 493.3(a)(2), and under the unreviewable grounds for denial in paragraph 164.524(a)(2).

5. Directory

LSSI may list your name, where you are located in its facilities, your general medical condition and your religious affiliation in an LSSI directory. This information may be provided to members of the clergy. This information, except your religious affiliation, may be provided to other people who ask for you by name. If you do not want LSSI to list this information in its directory and provide it to clergy and others, you must tell LSSI that you object.

6. Notification and communication with family

LSSI may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, LSSI will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, LSSI health professionals will use their best judgment in communication with your family and others.

7. Required by law

As required by law, LSSI may use and disclose your health information.

8. Public health

As required by law, LSSI may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

9. Health oversight activities

LSSI may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.

10. Judicial and administrative proceedings

LSSI may disclose your health information in the course of any administrative or judicial proceeding.

11. Law enforcement

LSSI may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

12. Deceased person information

LSSI may disclose your health information to coroners, medical examiners and funeral directors.

13. Organ donation

LSSI may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

14. Research

LSSI may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board (IRB) or the Management Team of Lutheran Social Services of Illinois (LSSI), this organization’s approval body for research activities.

15. Public safety

LSSI may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

16. Specialized government functions

LSSI may disclose your health information for military, national security, prisoner and government benefits [Note: disclosures for government benefits purposes are limited to health plans only].

17. Workers compensation

LSSI may disclose your health information as necessary to comply with workers compensation laws.

18. Marketing

LSSI may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.

19. Fund-raising

LSSI may contact you to participate in fund-raising activities for Lutheran Social Services of Illinois.

20. Change of Ownership

In the event that Lutheran Social Services of Illinois is sold or merged with another organization, your health information/record will become the property of the new owner.

II. When Lutheran Social Services of Illinois May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Lutheran Social Services of Illinois (LSSI) will not use or disclose your health information without your written authorization. If you do authorize LSSI to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

III. Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Lutheran Social Services of Illinois is not required to agree to the restriction that you requested.

You have the right to receive your health information through a reasonable alternative means or at an alternative location. Requests for reasonable alternative means shall be made in writing; specifying the alternative method; how payment for such method is to be made if it is determined by Lutheran Social Services of Illinois that the method incurs additional expense, etc.

You have the right to inspect and copy your health information.

You have a right to request that Lutheran Social Services of Illinois (LSSI) amend your health information that is incorrect or incomplete. LSSI is not required to change your health information and will provide you with information about LSSI’s procedures for contesting a denial.

You have a right to receive an accounting of disclosures of your health information made by Lutheran Social Services of Illinois, except that LSSI does not have to account for the disclosures described in parts 1. (treatment), 2. (payment), 3. (health care operations), 4. (information provided to you), 5. (directory listings) and 16. (certain government functions) of section I of this Notice of Privacy Practices.

You have a right to a paper copy of this Notice of Privacy Practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the office of the:

Privacy Official
c/o Lutheran Social Services of Illinois
1001 E. Touhy Avenue, Ste. 50
Des Plaines, Illinois 60018
Tele: 847.635.4600

IV. Changes to this Notice of Privacy Practices

Lutheran Social Services of Illinois (LSSI) reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, LSSI is required by law to comply with this Notice.

LSSI will communicate revisions to this Notice by posting such revisions in a conspicuous place, provide the revised notice on the agency’s Web site and allow thirty (30) days before effective date of implementation for the new revisions.

V. Complaints

Complaints about this Notice of Privacy Practices or how Lutheran Social Services of Illinois (LSSI) handles your health information should be directed to the office of the:

Privacy Official
c/o Lutheran Social Services of Illinois
1001 E. Touhy Avenue, Ste 50
Des Plaines, Illinois 60018
Tele: 847.635.4600

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Department of Health and Human Services

Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, DC 20201
Tele: 202.514.2000

The undersigned acknowledges receipt of this “Notice of Privacy Practices” as provided at the time of initial service delivery.*

Client Signature__________________________________________

Date _______________