Privacy policy.
THIS NOTICE DESCRIBES HOW MEDICAL, INCLUDING MENTAL HEALTH, INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice gives you information required by law about the duties and privacy practices of MK Counseling and Wellness to protect the privacy of your protected health information.
During the process of providing mental health and other services to you, MK Counseling and Wellness will obtain, record, and use information about you that is protected health information. MK COUNSELING AND WELLNESS may also receive and maintain financial and billing information about you. MK COUNSELING AND WELLNESS will not use or disclose your protected health information, except as described below.
I. USES AND DISCLOSURES OF PROTECTED INFORMATION
A. General Uses and Disclosures Not Requiring the Client’s Consent. MK COUNSELING AND WELLNESS will use and disclose protected health information in the following ways:
1. Treatment. Treatment refers to the provision, coordination, or management of health care, including mental health care, and related services by one or more health care providers. For example, MK COUNSELING AND WELLNESS staff involved with your care may use your information to plan your course of treatment and consult with other staff to ensure the most appropriate methods are being used to assist you.
2. Payment. Payment refers to the activities undertaken by a healthcare provider, including a mental health provider, to obtain or provide reimbursement for the provision of health care. For example, MK COUNSELING AND WELLNESS will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company for services provided. The information provided to insurers and other third party payors may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment.
3. Health Care Operations. Health Care Operations refers to activities undertaken by MK COUNSELING AND WELLNESS that are regular functions of management and administrative activities. For example, MK COUNSELING AND WELLNESS may use your health information in monitoring of service quality, staff training and evaluation, peer review, legal services, auditing functions, compliance programs, business planning, and accreditation, certification, licensing and credentialing activities.
4. Contacting the Client. MK COUNSELING AND WELLNESS may contact you to remind you of appointments, to tell you about or recommend possible treatment options or alternatives that may be of interest to you, and to tell you about health-related benefits or other services that might be of benefit to you.
provided that you have been given notice and an opportunity for a hearing; (c) when there is a legal duty to warn or take action regarding imminent danger to a specific person or persons; (d) when required to report certain communicable diseases and certain injuries; and (e) when a Coroner is investigating the client’s death.
6. Health Oversight Activities. MK COUNSELING AND WELLNESS may disclose protected health information to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the healthcare system, government health care benefit programs, regulatory programs or determining compliance with program standards.
7. Crimes on the premises or observed by MK COUNSELING AND WELLNESS personnel. Crimes that are observed by MK COUNSELING AND WELLNESS staff, that are directed toward staff, or occur on MK COUNSELING AND WELLNESS ’s premises will be reported to law enforcement.
8. Business Associates. Some of the functions of MK COUNSELING AND WELLNESS are provided by contracts with business associates. For example, some administrative, clinical, quality assurance, billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
9. Research. MK COUNSELING AND WELLNESS may use or disclose protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulation and applicable state law are followed. For example, the Illinois Mental Health and Developmental Disabilities Confidentiality Act permits MK COUNSELING AND WELLNESS to disclose your mental health records for research, without consent, provided that personally identifiable data is removed prior to disclosure.
10. Involuntary Clients. Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed.
11. Family Members. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
12. Fund Raising. MK COUNSELING AND WELLNESS may contact clients as a part of its fund raising activities. In such case MK COUNSELING AND WELLNESS will disclose only limited information about clients including: demographic information (name, address, other contact information, age, gender, and date of birth); dates of health care provided; department of service; treating physician; whether there was a positive or negative outcome; and health insurance status. If a client does not want us to contact them for fundraising efforts, the client has the right to opt-out of receiving such communications.5. Required by Law. MK COUNSELING AND WELLNESS will disclose protected health information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect; (b) when court ordered to release information,
13. Special Situations. MK COUNSELING AND WELLNESS is permitted to use or disclose your health information without your written authorization in connection with: PMK Counseling and Wellness lic Health Activities (e.g., to report births, deaths, communicable diseases, injuries or disabilities); Food and Drug Administration (relative to adverse events or post-marketing surveillance); Law Enforcement (in limited circumstances, such as to identify or locate suspects, fugitives, witnesses or victims of crime, to report deaths from crimes or crimes on premises or to prevent or lessen a serious and imminent threat to the health or safety of the community or an individual); Legal Proceedings (if ordered to do so by a court or if we receive an appropriate MK Counseling and Wellness subpoena); Worker’s Compensation (in connection with work-related injuries and pursuant to applicable law); Coroners, Medical Examiners and Funeral Directors (consistent with applicable law); Organ and Tissue Donation (consistent with applicable law); Military, Veterans, National Security and Other Government Purposes (e.g., if you are a member of the armed forces, we may release your medical information as required by military command authorities); and Correctional Institutions (if you are an inmate, we may disclose medical information necessary for your health and the health and safety of other individuals in the institution or its agents).
B. Client Authorization or Release of Information. Other uses and disclosures of protected health information not covered by this Notice or the laws that apply to us will be made only with your written permission, including (i) most uses and disclosures of psychotherapy notes and other highly confidential information (e.g., certain mental health and development disability services, alcohol and drug abuse treatment, HIV/AIDS testing or treatment, venereal disease treatment, sexual assault records, or genetic testing); (ii) most uses and disclosures of your protected health information for marketing purposes; and (iii) disclosures that constitute the sale of your protected health information. If you provide us permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
In accordance with 740 ILCS 110/5, we will obtain your consent to disclose your mental health information, unless an exception applies. Consent to disclose mental health information shall be in writing, shall not be part of a general consent form, and shall specify the following: 1) the person or agency to whom disclosure is being made; 2) the purpose for which disclosure is to be made; 3) the nature of the information to be disclosed; 4) the right to inspect and copy the information to be disclosed; 5) the consequences of a refusal to consent, if any; 6) the calendar date on which the consent expires (if date is not provided, the information may only be disclosed on the date consent is received); and 7) the right to revoke the consent at any time.
II**. YOUR RIGHTS AS A CLIENT**
A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the protected health information MK COUNSELING AND WELLNESS has regarding you, in the designated record set. Access must be provided to you within 30 days and we may charge a reasonable, cost-based fee. You can request access to an electronic or paper copy of your protected health information. You may also request a summary of your health information. There are some limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask MK COUNSELING AND WELLNESS staff for the appropriate request form.
B. SMS. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties
C. Amendment of Your Record. You have the right to request that MK COUNSELING AND WELLNESS amend your protected health information. MK COUNSELING AND WELLNESS is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. If we deny your request for an amendment, we will provide you with additional information, in writing, regarding the denial within 60 days. To make a request, ask MK COUNSELING AND WELLNESS staff for the appropriate request form using the contact information in Section III(D) below.
D. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures MK COUNSELING AND WELLNESS has made regarding your protected health information in the four (4) years immediately preceding your request. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you or disclosures made pursuant to a signed Authorization. There are other exceptions that will be provided to you, should you request an accounting. To make a request, ask MK COUNSELING AND WELLNESS staff for the appropriate request form.
E. Additional Restrictions. You have the right to request a restriction or limitation on the protected 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 protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request, unless your request is that we not disclose information to a health plan for payment or health care operations activities when you have paid for the services that are the subject of the information out-of-pocket in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To make a request, ask MK COUNSELING AND WELLNESS staff for the appropriate request form.
F. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from MK COUNSELING AND WELLNESS by alternative means or at alternative locations. For example, if you do not want MK COUNSELING AND WELLNESS to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask MK COUNSELING AND WELLNESS staff for the appropriate request form.
G. Copy of this Notice. You have a right to obtain a paper copy of this Notice upon request at any time, even if you have agreed to receive this Notice electronically.
H. Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your protected health information. We will verify that has this person has authority and can act for you before we take any action.
III. ADDITIONAL INFORMATION
A. Privacy Laws. MK COUNSELING AND WELLNESS is required by State and Federal law to maintain the privacy of protected health information. MK COUNSELING AND WELLNESS follows any federal or state law that gives greater privacy protections than HIPAA. For example, MK COUNSELING AND WELLNESS follows the Illinois Mental Health and Developmental Disabilities Confidentiality Act concerning mental health records at 740 ILCS 110. In addition, MK COUNSELING AND WELLNESS is required by law to provide clients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of this Notice.
B. Terms of the Notice and Changes to the Notice. MK COUNSELING AND WELLNESS is required to abide by the terms of this Notice, or any amended Notice that may follow. MK COUNSELING AND WELLNESS reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be available upon request and will be posted.
C. Breach Notification. MK COUNSELING AND WELLNESS is required to notify you following a breach of your protected health information that has not been secured in a certain manner.
D. Complaints Regarding Privacy Rights. If you believe MK COUNSELING AND WELLNESS has violated your privacy rights, you have the right to complain to MK COUNSELING AND WELLNESS, owner . To file your complaint, contact MK COUNSELING AND WELLNESS ’s Owner, Melissa Kwafo, at 8001 Linclon Avenue., Suite 711, Skokie IL, 600777 or via email at mkcounselingandwellness@gmail.com . You also have the right to complain to the Office for Civil Rights, U.S. Department of Health & Human Services, 233 N. Michigan Avenue, Suite 1300, Chicago, IL 60601, (800) 368-1019; (800) 537-7697 (TDD), (312) 886-1807 FAX. It is the policy of MK COUNSELING AND WELLNESS that there will be no retaliation for your filing of such complaints.
E. Additional Information. If you desire additional information about your privacy rights at MK COUNSELING AND WELLNESS, please contact Owner, Melissa Kwafo, mkwafo@mkcounselingchicago.com.
F. Effective Date. This Notice is effective December 21, 2020.
PRESENTATION OF THE NOTICE OF PRIVACY PRACTICES
MK COUNSELING AND WELLNESS must provide Clients with a Notice of Privacy Practices (the “Notice”), informing them of the uses and disclosures of Protected Health Information that may be made by MK COUNSELING AND WELLNESS, and the Client’s rights and MK COUNSELING AND WELLNESS’s legal duties with respect to Protected Health Information. MK COUNSELING AND WELLNESS will ask each Client, or the Client’s legal guardian, to sign an acknowledgment indicating that the Notice was received. That acknowledgment is found on MK COUNSELING AND WELLNESS’s mandatory disclosure form. In addition, for Clients who have already signed their mandatory disclosure form, you may use the Acknowledgment of Receipt of Notice form.
PRESENTATION OF THE NOTICE AND ACKNOWLEDGMENT
Provision of Notice. Except in an emergency treatment situation, the Notice must be provided to a Client no later than the date of the first service delivery, including service delivered electronically.
Written Acknowledgement of Receipt of Notice. When a Notice is provided to a Client, MK COUNSELING AND WELLNESS will make a good faith effort to obtain a written acknowledgement of the Client’s receipt of the Notice. The Client or the Client’s guardian will be asked to sign the Notice acknowledgment on MK COUNSELING AND WELLNESS’s Acknowledgement of Receipt of Notice form.
Temporary emergency exception. In an emergency treatment situation, the Notice and acknowledgment will be provided to the Client or the Client’s legal guardian as soon as reasonably practicable after the emergency treatment situation.
Unsigned Acknowledgements. If MK COUNSELING AND WELLNESS is unable to obtain a written acknowledgement from the Client or the Client’s legal guardian, MK COUNSELING AND WELLNESS will document its good faith efforts to obtain the acknowledgement and the reason the signature was not obtained. The appropriate Personnel will do this by completing the appropriate section of the Acknowledgment of Receipt of Notice form.
Posting of the Notice and additional copies. The Notice must be posted in a clear and prominent location at MK COUNSELING AND WELLNESS’s physical treatment sites, and it must be available for Clients who request a copy.
Electronic Notice. If MK COUNSELING AND WELLNESS has a website that provides information about MK COUNSELING AND WELLNESS’s Client services, the Notice must be prominently posted on the web site and available electronically through the web site. Notice may be provided to a Client by email, if the Client agrees to electronic notice and such agreement has not been withdrawn. If the Notice is provided to a Client by email and MK COUNSELING AND WELLNESS knows that the email transmission has failed, a paper copy of the Notice will be presented to the Client. A Client who is the recipient of an electronic Notice retains the right to obtain a paper copy of the Notice upon request.
Inmate exception. MK COUNSELING AND WELLNESS is not required to provide the Notice to an Inmate. However, it is better to err in the direction of giving the Notice when in doubt.
Revised Notices. Whenever MK COUNSELING AND WELLNESS revises the Notice, MK COUNSELING AND WELLNESS will make the revised Notice available upon request on or after the effective date of the revisions and will prominently post the revised Notice at its delivery site.
Documentation. MK COUNSELING AND WELLNESS must document its compliance with the requirements related to the Notice by retaining copies of the Notices issued by MK COUNSELING AND WELLNESS and if applicable, any written acknowledgement of receipt of the Notice or documentation of good faith efforts to obtain such written acknowledgment.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.