1. USE AND DISCLOSURE OF YOUR HEALTH INFORMATION


In its provision of services, ICPMG obtains health information about you and stores it in paper form and on computers. This compilation of information is commonly referred to as your medical record. The information contained in your medical record includes information that enables us to identify and contact you (for example, your name, address, phone number, etc.), information about your medical condition and the treatment of your medical condition, and information about sources of payment for your medical care, among other things. The medical record is the property of ICPMG and/or your health care provider, but the information in the medical record belongs to you. The law permits ICPMG to use and disclose the information in your medical record for the following purposes:


1. Treatment. ICPMG discloses your medical information to physicians and other health care providers who are involved in providing the care you need. We also may disclose your medical information to your family, close personal friends, personal representatives, and others identified by you to the extent such information is relevant to their involvement in your health care or payment related to your health care.



2. Payment. ICPMG uses and discloses information about you to obtain payment for the health care services provided on your behalf. For example, ICPMG provides certain information about you to your health plan to obtain payment for your health care services.



3. Health Care Operations. ICPMG uses and discloses information about you to operate ICPMG's business. For example, ICPMG uses and discloses your information to improve the quality of care you receive and to evaluate the competence and qualifications of our staff. ICPMG may use and disclose information about you to your health plan to obtain authorization for the provision of additional services or to obtain a referral to a physician. ICPMG also may also use and disclose your information for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. ICPMG may share your medical information with its "business associates" that perform administrative and other services for ICPMG. ICPMG has a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your information to the same extent ICPMG is required to protect your information. Upon request, ICPMG may share your information with other health care providers, health care clearinghouses and health plans that have a relationship with you to assist them in (i) their performance of health care quality assessment and improvement activities, (ii) their efforts to improve their provision of health care services or to reduce health care costs, (iii) their evaluation of the competence, qualifications and performance of their health care professionals, (iv) their training programs, (v) their accreditation, certification and licensing activities and (vi) their health care fraud and abuse detection and compliance efforts.



4. Appointment Reminders. ICPMG may use your identifying information to contact you and to remind you about health care appointments. If you are not home, we may leave information about the date, time and location of your appointment on your answering machine or in a message left with the person answering the phone, but we will not disclose the purpose of the appointment or the nature of your medical condition.



5. Sign-In Sheet. For security purposes, ICPMG requires all visitors to register at its reception desk. Consequently, your name may be seen by and disclosed to other visitors of ICPMG. We may also call out your name when we are ready to see you.



6. Notification and Communication With Family and Friends. ICPMG may use your information to notify (or to enable another authorized person to notify) your family, your personal representative or another person responsible for or involved in your care about your location and your general condition. In the event of a disaster, ICPMG may disclose your information to a relief organization that is coordinating notification efforts. If you are able and available to agree or object to ICPMG's disclosure of your information to the people described above, you will be given an opportunity to object to the disclosures, although ICPMG may disclose your information during a disaster despite your objection if ICPMG believes such disclosure is necessary to respond to the emergency. If you are unable or unavailable to agree or object, ICPMG will use its best judgment when communicating with your family, friends and others.



7. Marketing. ICPMG may contact you to give you information about products or services related to your treatment, case management and care coordination, or to direct or recommend other treatment or health-related benefits and services that may be of interest to you, or to provide you with small gifts. ICPMG also may encourage you to purchase a product or service when we see you. ICPMG will not disclose your medical information to third parties for marketing purposes without first obtaining your written authorization. If ICPMG will receive any financial remuneration from a third-party to market products or services to you, the form of authorization provided by ICPMG will explain that such remuneration is involved.



8. Fundraising. ICPMG may user or disclose the following information about you to a business associate or to an institutionally-related foundation for the purpose of raising funds for ICPMG's own benefit, without an authorization from you: (i) your demographic information, including your name, address, other contact information, age, gender, and date of birth; (ii) the dates of health care was provided to you; (iii) department of service information; (iv) the name of your treating physician; (v) outcome information; and (vi) your health insurance status. ICPMG's fundraising materials will include a description of how you may opt out of receiving any further fundraising communications and ICPMG will use reasonable efforts to ensure you do not receive future fundraising communications if you exercise your right to opt out. The method for you to elect not to receive further fundraising communications will not cause you to incur an undue burden or more than a nominal cost. ICPMG will not condition treatment or payment based on your decision to accept or decline fundraising communications.



9. Required By Law. ICPMG will use and disclose your information to the extent required by applicable laws, but we will limit our use and disclosure to the amount and type of information required to be disclosed. When the law requires us to report abuse, neglect or domestic violence, to respond to judicial or administrative proceedings, or to disclose your information to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.



10. Public Health. ICPMG may, and is sometimes required by law, to disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury or disability; reporting elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration certain problems with products and reactions to medications; and reporting disease or infection exposure. When ICPMG reports suspected elder or dependent adult abuse or domestic violence, ICPMG will inform you or your personal representative promptly of such report unless, in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.



11. Health Oversight Activities. ICPMG may, and is sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to limitations imposed by applicable laws.



12. Judicial and Administrative Proceedings. ICPMG may, and is sometimes required by law, to disclose your health information in the course of an administrative or judicial proceeding. ICPMG also may disclose your information in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if a court or administrative order has resolved your objections.



13. Law Enforcement. ICPMG may, and is sometimes required by law, to disclose your health information to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness or missing person, or complying with a court order, warrant, grand jury subpoena or other law enforcement purpose.



14. Coroners. ICPMG may, and may be required by law, to disclose your health information to a coroner in connection with his or her investigation of your death.



15. Organ or Tissue Donation. ICPMG may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.



16. Public Safety. ICPMG may, and is sometimes required by law, to 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.



17. Specialized Government Functions. ICPMG may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.



18. Workers' Compensation. ICPMG may disclose your health information as necessary to comply with worker's compensation laws. For example, to the extent your care is covered by workers' compensation, ICPMG may make periodic reports to your employer about your condition. ICPMG may also be required by law to report cases of occupational injury or occupational illness to your employer or your employer's workers' compensation insurer.



19. Change of Ownership. If ICPMG is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.



20. Research. ICPMG may disclose your health information to researchers if your written authorization is not required for such disclosure, as approved by an Institutional Review Board or privacy board or in compliance with governing law.



21. Fundraising. ICPMG may use or disclose your demographic information and the dates you received treatment in order to contact you for fundraising activities. If you do not want to receive these materials, notify the Privacy Official listed at the top of this notice.



2. WHEN ICPMG WILL NOT USE OR DISCLOSE YOUR HEALTH INFORMATION



1. Psychotherapy Notes. ICPMG will obtain your authorization for any use or disclosure of your psychotherapy notes, except: (a) to carry out the following treatment, payment, or health care operations: (1) use by the originator of the psychotherapy notes for your treatment; (2) use or disclosure by ICPMG for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (3) use or disclosure by ICPMG to defend itself in a legal action or other proceeding brought by you; (b) use or disclosure to the Secretary of the Department of Health and Human Services or other applicable government agencies to the extent required to establish ICPMG's compliance with applicable laws; (c) when required by law; (d) to comply with oversight requirements with respect to the originator of the psychotherapy notes; (e) to a coroner or medical examiner, as necessary and appropriate, or (f) to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.



2. Marketing. As further described in section A.5 above, ICPMG will obtain your authorization for any use or disclosure of your protected health information for marketing purposes, unless the marketing communication is in the form of (a) a face-to-face communication made to you by ICPMG, or (b) a promotional gift of nominal value provided to you by ICPMG.



3. Sale of Protected Health Information. ICPMG will obtain your authorization for any disclosure of your protected health information that constitutes a sale of your protected health information. Such authorization will state that the sale will result in payment to ICPMG.



3. YOUR HEALTH INFORMATION RIGHTS



1. Right to Request Special Privacy Protections. You have the right to request in writing that ICPMG restrict its use and disclosure of your health information. ICPMG may accept or reject your request in its sole discretion, and will notify you of its decision. Notwithstanding the foregoing, unless otherwise required by law, ICPMG will comply with your request to restrict disclosure of your health information to a health plan for purposes of carrying out payment or health care operations if the health information pertains solely to a health care item or service for which your health care provider has been paid in full by you or by a person other than the health plan.



2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. ICPMG will comply with all reasonable written requests that specify how or where you wish to receive these communications.



3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your information, you must submit a written request detailing the information you would like to access that specifies whether you would like to inspect the information or obtain a copy of the information. ICPMG will charge a reasonable fee, as allowed by law, for copies of your health information. ICPMG may deny your request for access under limited circumstances. If ICPMG denies your request to access your child's records because we believe allowing access would be reasonably likely to cause substantial harm to your child, you will have a right to appeal our decision. If ICPMG denies your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional for a second opinion regarding whether you should be allowed access to the psychotherapy notes.



4. Right to Amend or Supplement Your Medical Record. You have a right to request that ICPMG amend information you believe is incorrect or incomplete. You must make your amendment request in writing and must include the reason you believe the information is inaccurate or incomplete. ICPMG is not required to amend your health information. ICPMG may deny your amendment request if it does not have the information, if it did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information or if ICPMG determines the information is accurate and complete. If we deny your amendment request, we will inform you about the reasons for the denial and explain how you can respond to our denial. You also have the right to request that we add to your medical record a statement of up to 250 words concerning any information in your medical record that you believe is incomplete or incorrect.



5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by ICPMG, except that ICPMG does not have to account for disclosures of information made to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 16 (specialized government functions) of Section A of this notice of privacy practices, or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or disclosures to a health oversight agency or law enforcement official to the extent ICPMG has received notice from such agency or official that providing an accounting would be reasonably likely to impede their activities.



6. Right to Copy of Notice. You have a right to a paper copy of this notice of privacy practices, even if you have previously requested its receipt by e-mail.
   
   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 Privacy Official identified at the top of this notice.


4. AMENDMENTS TO THIS NOTICE OF PRIVACY PRACTICES


ICPMG reserves the right to amend this notice of privacy practices at any time without prior notice. Until such amendment is made, ICPMG is required by law to comply with this notice. After the notice is amended, the revised notice of privacy practices will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area and will post the current notice on our website.


5. COMPLAINTS


ICPMG understands the importance of maintaining the confidentiality of your personal information. If you have any complaints about this notice of privacy practices or about how ICPMG handles your health information, please contact the Privacy Official identified at the top of this notice as soon as possible so we can address your concerns. If you would like, you also may submit a formal complaint to the Secretary of the Department of Health and Human Services, Office of Civil Rights. You will not be penalized for filing a complaint with us or with the Department of Health and Human Services.

HIPAA Authorization Form