Southeastern Illinois Counseling Centers, Inc.
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.
We respect client confidentiality and only release confidential information about you in accordance with Illinois and federal law. This notice describes our policies related to the use of the records of your care generated by this agency.
PRIVACY CONTACT. If you have any questions about this policy or your rights you may contact the HIPAA Privacy Officer at Drawer M, Olney, Illinois 62450 or call 618-395-4306.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
In order to effectively provide you care, there are times when we will need to share your confidential information with others. This includes for:
Treatment. We may use or disclose treatment information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside our agency that we are consulting with or referring you to.
Payment. With your written consent, information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes.
Healthcare Operations. We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.
Information Disclosed Without Your Consent. Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:
Emergencies. Sufficient information may be shared to address the immediate emergency you are facing.
Follow Up Appointments/Care. We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
As Required by Law. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.
Coroners. We are required to disclose information about the circumstances of your death to a coroner who is investigating it.
Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations inspections and licensure. We are also required to share information, if requested, with the U.S. Department of Health and Human Services to determine our compliance with federal laws related to health care and to Illinois state agencies that fund our services.
Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.
Fundraising. As a not for profit provider of health care services we need assistance in raising money to carry out our mission. We may contact you to seek a donation.
CLIENT STATEMENT OF RIGHTS
Southeastern Illinois Counseling Centers, Inc. is committed to insure that clients receive professional and humanistic services directed toward their needs in a manner that protects their dignity and feelings of self-worth. The following Statement of Rights has been formulated and is available to your family or legal guardian if appropriate.
You have the following rights under Illinois and federal law:
Copy of Record. You are entitled to inspect the client record Southeastern Illinois Counseling Centers, Inc. has generated about you. We may charge you a reasonable fee for copying and mailing your record to others at your request. You may have a copy of your record for a minimal fee. You will be asked to provide your full name, social security number, date of birth, purpose of request, phone number where we may reach you and current mailing address if you want the record mailed. There will be an additional mailing fee. If you wish to pick up the copies at one of our local offices, you will be presented with an invoice for copying fees, but you must pick it up in person and present picture ID or another valid form of identification.
Release of Records. You may consent in writing to release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.
Restriction on Record. You may ask us not to use or disclose part of the clinical information. This request must be in writing. Southeastern Illinois Counseling Centers, Inc. is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information. The request should be given to the Privacy Officer.
Contacting You. You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct.
Amending Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this contact the Privacy Officer and ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.
Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your confidential information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to our Privacy Officer. We will notify you of the cost involved in preparing this list.
Questions and Complaints. If you have any questions, or wish a copy of this Policy or have any complaints, you may contact our Privacy Officer in writing at our office for further information. You also may complain to the Secretary of U.S. Department of Health and Human Services if you believe Southeastern Illinois Counseling Centers, Inc. has violated your privacy rights. We will not retaliate against you for filing a complaint.
You have the right to be treated with dignity and respect in a manner reflecting quality, professional, and ethical standards.
You retain and will be kept informed of all human, statutory, constitutional, and civil rights guaranteed by law, such as the right to legal counsel and all other due process requirements when necessary.
Services will be provided to you and/or your family members without discrimination. Ethnic background, (person or social creed), racial membership, age, sex, marital status, sexual orientation, religion, physical or mental disability, HIV status or criminal record will not affect our services to you.
You will be required to pay for services, but will not be refused based on lack of financial resources. You will be provided a sliding scale fee based upon your income.
You will be informed as to facility rules and regulations regarding conduct. Services will be provided with a minimum of waiting time. Center service hours will be reasonably convenient to all clients requesting services. A service provider will be assigned to you. A follow-up plan will be developed to insure the continuity/need of mental health services.
All information concerning you is held confidential and released only through procedures consistent with the law and professional ethics. Your records can only be released with your permission, by an order of a court of law, if your guardian gives permission, or an emergency situation exists.
Confidentiality is defined and protected under the Illinois Department of Mental Health and Developmental Disabilities Confidentiality Act.
Continuing training and orientation for new employees in the principles of confidentiality and privacy is provided to insure your rights to confidentiality.
You have the right to review and approve any information being requested by another provider giving services to you. You must sign a release for any such information sent. You must be informed and given written consent before therapy sessions can be taped or viewed by other professionals. The use of products of special observation shall be fully explained to you.
You will be advised of the positive effects and possible complication of any drugs or medications prescribed by any physician involved in your services. You will not be forced to take any medication. You must be informed and give written consent before receiving medication prescriptions.
You have the right to an itemized charge, a payment plan, and access to written information about the Center’s fee schedule, rules, and reimbursement sources.
You have a right to an individual plan for services and will be expected (if age 12 or older) to participate in your plan for services. Any potential specific risks will be explained to you. If you are a minor, you have the same right in conjunction with your parents. Your family is also encouraged to participate as appropriate. Your treatment plan will receive periodic review.
You have the right to know the name and professional credential of anyone providing services to you. You have the right to provision of an adequate number of competent, qualified, and experienced professional clinical staff to supervise and implement your treatment plan.
You have the right to be treated in the least restrictive environment consistent with your welfare and the welfare of others.
You may review your clinical records upon written request. You may request an in-house review of your treatment plan or the opinion of a consultant.
You have the right to have services explained to you in a language you understand.
You will receive an explanation of the nature of care, procedures, and alternate treatment procedures available or if certain services are refused to you.
You have the right to refuse to participate in or be interviewed for research purposes. This will not compromise your accessibility to services. You will sign and date a consent form.
You have the right to terminate services at any time except in an emergency situation, and the right not to be denied treatment or referral as a form of reprisal, except that no clinician shall be obliged to administer treatment which is contrary to their clinical judgment.
It is your right not to be permitted to endanger yourself or others in accordance with Illinois law in the clinical judgment of the physician, therapist, or other personnel. If you need to be hospitalized for your safety or the safety of others, and you refuse, the staff shall initiate the required procedure for involuntary hospitalization.
Any justification for restriction of client rights will be documented in the client’s clinical record. The client, affected by such restriction, his or her parent or guardian and any agency designated, will be notified of the restriction.
You have the right to legal recourse; you have the right to confer with family, attorney, physician, clergyman, and others at any time. You have the right to obtain a second opinion, at your own expense, at any time.
Consistent with providing professional and quality services, you will be given an opportunity to evaluate all aspects of your services and the personnel with whom you were involved. You will be asked to evaluate your services, in writing, during or upon completion of this process. It is possible to attend Treatment Team Staffing by written request.
If necessary to change your therapist or facility, this will be discussed with you.
If you feel your services have not been provided fairly or reasonably, you may present your concerns, in writing, to your counselor’s immediate supervisor. We have a form that will be provided to you for this purpose.
You have the right to be informed of your rights in a language you understand. Each client shall be given a copy of the Statement of Rights for his/her personal use. A copy of Client Rights is also posted in various areas of the facility.
OCCURRENCE OF CLIENT ABUSE OR NEGLECT
You have the right to receive services free from any abuse and/or neglect. You have the right to exercise any and all of these rights without being denied, suspended or terminated from services or have services reduced as a result of exercising these rights.
Policy: It is the policy of the Center to provide quality, client oriented services. In the event a client is dissatisfied with services or feels there has been an occurrence of abuse or neglect, the Center will review, investigate, and give written response to the charges. Procedure for filing a grievance will be posted in all offices. Staff that observe client abuse or neglect will follow same procedure.
Procedure: What to do when you are the subject of neglect or abuse or if you observe someone being neglected or abused.
FIRST contact team leader and discuss the situation. Fill out the Client Grievance Form. If you get no action or would rather not discuss the situation with the team leader,
ask to see or schedule an appointment with the appropriate Clinical Supervisor or Program Coordinator. The Clinical Supervisor or Program Coordinator will see clients either by appointment or on a walk-in basis if necessary.
If the grievance remains unresolved, he/she may request a meeting with the Executive Director, phone (618) 395-4306.
You have a right to report any infringements of your rights to the following organizations:
GAC (Guardianship and Advocacy Commission)
421 East Capitol Street 527 South Wells, Suite 300
Springfield, Illinois 62701 Chicago, Illinois 60607
Department of Mental Health and Developmental Disabilities
402 South Spring Street 100 West Randolph St., Suite 6-400
Springfield, Illinois 62765 Chicago, Illinois 60601
Equip for Equality
427 East Monroe Street
Springfield, Illinois 62701
Office of Inspector General
901 Southwind Road
Springfield, Illinois 62703
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
You have the right to request agency staff assistance in contacting the above organizations.
EACH CLIENT SHALL BE GIVEN A COPY OF THE STATEMENT OF RIGHTS FOR HIS/HER PERSONAL USE. SUCH COPY WILL BE EXPLAINED TO THE CLIENT, IF NECESSARY, IN A LANGUAGE OR METHOD OF COMMUNICATION THE CLIENT CAN UNDERSTAND.
SHOULD THERE BE ANY REVISIONS TO THIS “PRIVACY PRACTICES AND CLIENT RIGHTS”, EACH CLIENT WILL BE OFFERED THESE REVISIONS.