KENOSIS COUNSELING CENTER and COUNSELINGPROS, INC. -- NOTICE OF PRIVACY PRACTICES

THIS DOCUMENT DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN HAVE ACCESS TO THIS INFORMATION. EFFECTIVE BEGINNING APRIL 14, 2003. PLEASE REVIEW CAREFULLY.

OUR PLEDGE REGARDING YOUR PERSONAL INFORMATION

This notice of privacy describes how we may use and disclose your protected health information to carry out treatment, payment and for other purposes permitted or required by law. It also describes your right to access and control your protected health information. The following categories describe different ways that we use and disclose medical information. Information may be disclosed in writing, orally or electronically.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by Kenosis Counseling Center, Inc., our employees and others that are involved in your care for the purpose of providing psychotherapy services to you. Your protected health information may be disclosed to pay your psychotherapy bills and to support Kenosis Counseling Center’s operations.

For Treatment: We may use your medical information to provide you with treatment or services. We may disclose your medical information to doctors, nurses, technicians, medical students, psychotherapists, or other personnel who are involved in your care. We may disclose medical information about you to people outside Kenosis Counseling Center who may be involved in your medical care after you leave, such as family members, clergy or others we use to provide services that are part of your care.

Individuals Involved In Your Care or Payment for Your Care: We may disclose your protected health information to a friend or family member or other person specifically designated by you and who is involved in your medical care. We may also give medical information to someone who helps to pay for your care.

To Avert a Serious Threat to Health or Safety: We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Mental Health Oversight Activities: We may disclose your information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations and licensure.

Communicable Disease: We may disclose your protected health information, if authorized, to a person who may have been exposed to a communicable disease or may otherwise be at risk for contracting or spreading the disease or condition.

Abuse or Neglect: We may disclose your protected health information to a public health agent authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your health information to a governmental entity or agency authorized to receive such information if we believe that you have been the victim

of abuse, neglect or domestic violence. Disclosure would be consistent with the requirements of applicable federal and state law.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court order. We may also disclose health information about you in response to a valid subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do so by a law enforcement official; In response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about the criminal conduct at our office; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities: We may release health record information about you to authorized federal authorities for intelligence, counter-intelligence, and other national security activities by law.

Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Right to Inspect, Copy and Amend: You have a right to inspect and copy all disclosures of information, including treatment summaries. This does not include psychotherapy notes. If you feel any information from any disclosure is incorrect, you have the right to request an amendment. All requests to inspect and copy disclosures must be made in writing to Kenosis Counseling Center, Inc. Denial of requests may occur with some requests. For instance, a request made by one spouse for disclosures occurring during marital counseling will be denied.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of disclosures we have made of your health record information. Request must be made in writing, state a time period (no longer than six years) and may not include dates before April 14, 2003.

Right to Request Restrictions: You have the right to request a restriction or limitation on the ways your health record information is used. We are not required to agree to your request. If we agree, we will comply with your request, with the exception of emergency care. Specific request must be made in writing.

Right to Request Confidential Communications: You have the right to request that we communicate with you in a certain way or at a certain location. Request must be made in writing to Kenosis Counseling Center, Inc.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask for a copy any time.

Other Uses of Medical Information: Other disclosures and uses of your information will be made only with your written permission. You may revoke that permission, in writing, any time. Kenosis Counseling Center will be unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that was provided to you.

Changes to this Notice: We reserve the right to change this notice. Upon your request, we will provide you with any revisions.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with Kenosis Counseling Center, Inc. or with the Indiana Health Professions Bureau at 317-232-2960. All complaints must be submitted in writing.

If you have any questions about this notice contact CounselingPros.com & Kenosis Counseling Center, Inc. at 317-865-1674 or Toll Free at 1-877-865-1676.

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