THIS NOTICE DESCRIBES HOW MEDICAL RECORD INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

INTRODUCTION

This notice of Privacy Practices describes how we may use and disclose your protected health information determining your eligibility for services and for other purposes that are permitted or required by law.   This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights.   This notice further states the obligations we have to protect your medical/assessment records.   “Protected health information,” means health information (including identifying information about you) we have collected from you or received from your health care/service providers.   It may include information about your past, present or future physical or mental health or condition and the provision of your health care. We are required by Law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information.   We are also required to comply with the terms of our current Notice of Privacy Practices. We will use and disclose your medical/assessment records as described in each category below. For each category we will explain what we mean in general, but not describe all specific uses or disclosures of medical/assessment records.

1. Home of the Sparrow, Inc. will use your medical/assessment records to determine your eligibility for our services and for community, state and federally funded services.
2. Once you have signed our Consent to Use and Disclose Medical/Assessment Records Form, we will use and disclose your medical/assessment records to access and provide services for you.
3. Home of the Sparrow, Inc. may disclose your medical/assessment records without your consent to comply with laws that require disclosure when an individual is deemed to be a danger to himself or others or where there is suspected child/elder abuse and neglect.
4. Home of the Sparrow, Inc. may disclose information about you to a court administrative agency when a judge or administrative agency orders us to do so. We also may disclose medical/assessment records about you in legal proceedings without your permission or without a judge or administrative agency’s court order when:  you are a party to a legal proceeding and we receive a subpoena for your medical/assessment records. 
5. Home of the Sparrow, Inc. may disclose your medical/assessment records to a law enforcement official for law enforcement purposes when: a court order, subpoena, warrant, summons or similar process requires us to do so; or the information is needed to identify or locate a suspect, fugitive, material witness or missing person; or we report a death that we believe may be the result of criminal conduct; or we report criminal conduct on the premises of our offices; or we determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by you against yourself or another person; or the disclosure is otherwise required by law.
6. Home of the Sparrow, Inc.  may disclose information about a client who is a victim of a crime without a court order if or without being required to do so by law when it has been requested by law enforcement and the victim has agreed to the disclosure. In the case of the victim’s incapacity, we will disclose information only if the victim is not the subject of the investigation, the safety of the victim depends on disclosure and we determine that the disclosure is in the victim’s best interest.   In all cases Home of the Sparrow, Inc. will comply with the Illinois Mental Health and Developmental Disabilities  Confidentiality Act 740ILCS 110.
7. Home of the Sparrow, Inc. may disclose medical/assessment records about you as authorized by law.  We may also provide medical/assessment records about you to authorized federal officials so they may provide protection to the President of the United States federal officials for intelligence, counter intelligence, and other national security activities authorized.
8. Home of the Sparrow, Inc. will use your medical/assessment records in reporting to the Illinois Department of Human Services (IDHS) and the McHenry County Mental Health Board (MHB). State and county funders require proof of eligibility and accounting of the services being provided.  This information is transferred to the IDHS and the MHB electronically. Paper copies of this information will be provided to the IDHS and MHB upon their request.
9. Home of the Sparrow, Inc. may use your medical/assessment records among our program service staff to determine your eligibility for services and to access additional resources to meet your needs.
10. Home of the Sparrow, Inc. will use your medical/assessment records to review your services for the purposes of utilization review to ensure the appropriateness of the services you are receiving.
11. Once you have signed our Consent to Use and Disclose medical/assessment records form, we may use and disclose medical/assessment records about you for our operations. These uses and disclosures are necessary to run our organization and make sure that our clients receive quality care. These activities may include by way of example, quality assessment and improvement, reviewing the performance of our service coordinators, licensing, accreditation, business planning and development, and general administrative activities.
12. We may combine health information about many of our clients to decide what additional services we should offer, what services may no longer be needed, and whether certain services are effective. We may combine our health information with health information from other providers to compare how we are doing and see where We can make improvements in our services.  When we combine our health information with information of other providers, we will remove identifying information so others may use it to study healthcare or services without identifying specific clients.
13. We may mail you our agency newsletter or contact you about fundraising for our programs, services and operations unless you specifically request that we not do so.

Other than in the above mentioned circumstances, Home of the Sparrow, Inc. will not disclose your medical/assessment records without your written permission, called an “authorization”.  You have the right to cancel or revoke an authorization at any time.  If you revoke and authorization no further disclosure to that entity will be made.                                                                                                                              

YOUR RIGHTS REGARDING YOUR MEDICAL/ASSESSMENT RECORDS  

1. You have a right to request an opportunity to inspect or copy Medical/assessment records used to make decisions about your services.  If you request copies of the information, we may charge a fee for the cost of copying, mailing and supplies associated with your request.
2. For as long as we keep records about you, you have the right to request us to amend any medical/assessment records used to make decisions about your services.  To request an amendment, you must submit a written document to our Privacy Officer at 6213 Factory Rd., Suite A., Crystal Lake, IL 60014.    We may deny your request for an amendment if it is not in writing.  We may also deny your request if you ask us to amend information that was not created by us, or is not part of the information we maintain to make decisions about your services.  If we deny your request to amend, we will send you a written notice of the denial stating our reasons for the denial.  You will be offered an opportunity to provide a written statement disagreeing with the denial.  You may request that a copy of your requested amendment and our denial be attached to all future disclosures of the medical/assessment records that is the subject of your request. If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written request and the rebuttal to future disclosures of the medical/assessment records that is the subject of your request.
3. You have a right to request an accounting of the disclosure we have made of your medical/assessment records.  To request an accounting of the disclosures you must submit your request in writing to the Privacy Officer at 6213 Factory Rd., Suite A., Crystal Lake, IL 60014.  The request should state the time period for which you wish to receive an accounting.  This time period cannot be longer than six years and cannot include dates prior to April 15, 2005.
4. You have a right to request a restriction on the medical/assessment records we use or disclose about you. You may also ask that any part or all of your medical/assessment records not be disclosed to family members or friends who may be involved in your care. To request a restriction, you must either include it in the Consent for Use and Disclosure form or request the restriction in writing to the Privacy Officer at 6213 Factory Rd.., Suite A., Crystal Lake, IL 60014.
5. You have a right to request that we communicate with you about your medical/healthcare only in a certain location or through a certain method.  For example you may request that we contact you at work or by e-mail.  To request such a confidential communication, you must make a request in writing to the Privacy Officer at 6213 Factory Rd., Suite A., Crystal Lake, IL 60014.
6. You have a right to request a paper copy of this Notice of Privacy Practices at any time.  To obtain a paper copy, contact our Privacy Officer at 6213 Factory Rd., Suite A., Crystal Lake , IL 60014.
7. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services.   To file a complaint with us,  please submit your complaint in writing to the Home of the Sparrow, Inc. Privacy Officer, 6213 Factory Rd., Suite A., Crystal Lake, IL 60014.   We will not retaliate against you for filing a complaint.   Changes to this Notice     Home of the Sparrow, Inc. reserves the right to change the terms of its Notice of Privacy Practices based on the needs of the agency and changes in the state and federal law. 

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