THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, AS REQUIRED BY THE HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA). PLEASE REVIEW IT CAREFULLY.
The Center for Religion and Psychotherapy of Chicago (CRPC) is committed to protecting
your confidentiality. You may request a copy of this notice at any time. For additional
information about our privacy practices, please contact our Privacy Contact at 30 North
Michigan Avenue, Suite 1920. Chicago IL 60602, or at 312-263-4368 ext. 9075.
I. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: In order to protect your PHI, we use
and disclose the minimum necessary PHI about you for your treatment and for payment for services:
For Treatment. We use and disclose your PHI internally in the course of your treatment at
CRPC only to the minimum necessary to provide due care through our professional services. For example,
we may share information with another CRPC professional for the purpose of referral. If we need to
provide PHI outside CRPC for your treatment, we will ask you to sign an authorization for release of
For Payment. We may use and disclose the minimum PHI to obtain payment for services we provide
to you as delineated in our Guidelines for Clinical Services. For example, we may need to give
insurance companies or other agencies the minimum necessary PHI in order for them to reimburse you
for your payment of services/
II. PROTECTED HEALTH INFORMATION DISCLOSED WITHOUT YOUR CONSENT: Under Illinois and Federal law, your
PHI may be disclosed without your consent in the following circumstances:
Emergencies. If, in the course of CRPC’s provision of due care, we believe that you are
an immediate danger to yourself or to another, we may disclose PHI about you to the authorities,
and we may alert any other person who may be in danger.
Judicial and Administrative Procedures. We may disclose your PHI in the course of a judicial
proceeding in response to a valid court order or other lawful process; and in response to
administrative proceedings such as claims for Workers’ Compensation.
Child/Elder Abuse. If, in the process of providing due care, CRPC has not be successful in
resolving with you situations that are reportable by law, we may disclose PHI about you related
to the discernment of child and/or elder abuse or neglect.
Health oversight Activities. We may disclose PHI to healthcare oversight agencies such as the
U.S. Department of Health and Human Services or the American Association of Pastoral Counselors for
activities required by law. These might include activities required for monitoring our provision of
due care and assuring compliance with civil rights laws. In such instances the minimum necessary
PHI will be provided and CRPC will strive to maintain your anonymity.
Business Associates. CRPC may disclose the minimum necessary PHI to our business associates,
such as our answering service or accounting firm, if the information is necessary for such
services. All of our business associates sign legal contracts to protect your PHI and are not
allowed to use or disclose any of your PHI other than as specified in the contract, which strives
to preserve your privacy.
Research. Under certain circumstances, CRPC may use and disclose PHI for research, but only
after an approval process that includes a consent form for you to sign if you choose to
participate in the research project.
III. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right to Inspect and Copy. You have the right to observe and/or obtain copies of your PHI,
with some limited exceptions. Your request must be in writing. If you request a copy of your PHI,
a reasonable charge may be made for the costs incurred.
Right to Amend. You have the right to request that we amend your PHI. Your request must be in
writing, and it must explain why the information should be amended. We have the right to deny your
request under certain circumstances.
Right to an Accounting of Disclosures. You have the right to receive a list of disclosures of
your PHI for any purpose other than treatment, payment, or healthcare oversight activities. To
request an accounting of disclosures, you must submit your request in writing to our Privacy
Contact. Such accounting is available for disclosures made beginning April 14, 2003, and remains
available for 6 years after the last date of service at CRPC.
Right to Request Restrictions. You have the right to request a restriction or limitation on
your PHI that we use or disclose about you. For example, you may ask that we not disclose PHI to
an insurance company. While you are in treatment, a written request should be made with your
therapist. To request a restriction after therapy is completed, you must make a written request
to the Privacy Contact at CRPC. CRPC is not required to agree to your request. But we will
consider the request very seriously. If we agree, we will abide by our agreement unless the PHI
is needed in an emergency or by law, as previously stated above in this notice.
Right to Request Confidential Communications. You have the right to request that we communicate
with you regarding your PHI in a particular way or at a certain location. For example, you may ask
that we contact you only by mail or at work. You must make this request in writing and it must
specify the alternative means or location you would like us to use. We will make every attempt
to accommodate reasonable requests.
Right to Obtain a Paper Copy of this Notice. You have the right to download a copy of this
notice or otherwise receive a paper copy of this notice upon request.
Any other uses and disclosures of your PHI not set out in the information above will be made only with
your written authorization. You may revoke a written authorization for release of information at any time.
The revocation must be in writing and will become effective when it has been received by your therapist at
CRPC, and will only be for disclosures not already completed.
We reserve the right to change our privacy practices provided such changes are permitted by applicable
law. Before the effective date of a material change, however, we will change this Notice and make a new
Notice available. The terms of this Notice have been effective as of April 14, 2003.
QUESTIONS AND COMPLAINTS. If you believe that your privacy rights have been violated,
you may file a complaint with us, or you may file a complaint with the U.S. Department
of Health and Human Services. To obtain additional information, or to file a complaint
with us, contact your therapist or our Privacy Contact at 312-263-4368 ext. 9075. We
are required not to retaliate in any way if you choose to file a complaint.