examples of individually identifiable health information

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

Introduction

At Wichita Child Guidance Center, we are committed to treating and
using protected health information about you responsibly. This Notice
of Health Information Practices describes the personal information we
collect, and how and when we use or disclose that information. It also
describes your rights as they relate to your protected health
information. This Notice is effective April 14, 2003, and applies to
all protected health information as defined by federal regulations.

Understanding Your Health Record/Information

Each time you visit Wichita Child Guidance Center, a record of your
visit is made. Typically, this record contains your symptoms,
examination and test results, diagnoses, treatment, and a plan for
future care or treatment. This information, often referred to as your
health or medical record, serves as a:

• Basis for planning your care and treatment,

• Means of communication among the many health professionals who
contribute to your care,

• Legal document describing the care you received,

• Means by which you or a third-party payer (insurance company) can
verify that services billed were actually provided,

• A tool in educating heath professionals,

• A source of data for medical research,

• A source of information for public health officials charged with
improving the health of this state and the nation,

• A source of data for our planning and marketing,

• A tool with which we can assess and continually work to improve
the care we render and the outcomes we achieve,

Understanding what is in your record and how your health information
is used helps you to: ensure its accuracy, better understand who,
what, when, where, and why others may access your health information,
and make more informed decisions when authorizing disclosure to others

Your Health Information Rights

Although your health record is the physical property of Wichita Child
Guidance Center, the information belongs to you. You have the right
to:

• Obtain a paper copy of this notice of information practices upon
request,

• Request to inspect and/or copy your health record as provided for
in 45 CFR 164.524,

• Amend your health record as provided in 45 CFR 164.528,

• Obtain an accounting of disclosures of your health information as
provided in 45 CFR 164.528,

• Request communications of your health information by alternative
means or at alternative locations,

• Request a restriction on certain uses and disclosures of your
information as provided by 45 CFR 164.522, and

• Revoke your authorization to use or disclose health information
except to the extent that action has already been taken.

Our Responsibilities

Wichita Child Guidance Center

is required to:

• Maintain the privacy of your health information,

• Provide you with this notice as to our legal duties and privacy
practices with respect to information we collect and maintain about
you,

• Abide by the terms of this notice,

• Notify you if we are unable to agree to a requested restriction,
inspection or copy of PHI, and

• Accommodate reasonable requests you may have to communicate health
information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new
provisions effective for all protected health information we maintain.
Should our information practices change, we will mail a revised notice
to the address you’ve supplied us, or if you agree, we will email the
revised notice to you.

We will not use or disclose your health information without your
authorization, except as described in this notice. We will also
discontinue to use or disclose your health information after we have
received a written revocation of the authorization according to the
procedures included in the authorization.

For More Information or to Report a Problem

If have questions and would like additional information, you may
contact the practice’s Privacy Officer, Danica Burke at (316)
686-6671.

If you believe your privacy rights have been violated, you can file a
complaint with the practice’s Privacy Officer, at:

Wichita Child Guidance Center

415 North Poplar

Wichita, Kansas 67214

(316) 686-6671

or with the Office for Civil Rights, U.S. Department of Health and
Human Services, Washington, D.C. 20201. There will be no retaliation
for filing a complaint with either the Privacy Officer or the Office
for Civil Rights.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment.

For example:

Information obtained by a clinician, or other member of your health
care team will be recorded in your record and used to determine the
course of treatment that should work best for you. When appropriate
your clinician will document in your record his or her expectations of
the members of your health care team. Members of your health care team
will then record the actions they took and their observations. In that
way, the clinician will know how you are responding to treatment.

We will also provide your clinician or a subsequent health care
provider with copies of various reports that should assist in treating
you.

We will use your health information for payment.

For example

: A bill may be sent to you or a third-party payer (insurance
company). The information on or accompanying the bill may include
information that identifies you, as well as your diagnosis,
procedures, and supplies used.

We will use your health information for regular health operations.

For example

: Members of the clinical staff, the risk or quality improvement
manager, or members of the quality improvement team may use
information in your health record to assess the care and outcomes in
your case and others like it. This information will then be used in an
effort to continually improve the quality and effectiveness of the
healthcare and service we provide.

Business associates

: There are some services provided in our organization through
contacts with business associates. Examples include physician services
when hospitalization is indicated, billing and financial services, and
certain laboratory tests. When these services are contracted, we may
disclose your health information to our business associate so that
they can perform the job we’ve asked them to do and bill you or your
third-party payer for services rendered. To protect your health
information, however, we require the business associate to
appropriately safeguard your information.

Notification

: We may use or disclose information to notify or assist in notifying
a family member, personal representative, or another person
responsible for your care, your location, and general condition.

Communication with family

: Health professionals, using their best judgment, may disclose to a
family member, other relative, close personal friend or any other
person you identify, health information relevant to that person’s
involvement in your care or payment related to your care.

Research

: We may disclose information to researchers when their research has
been approved by an institutional review board that has reviewed the
research proposal and established protocols to ensure the privacy of
your health information.

Marketing

: We may contact you to provide appointment reminders or information
about treatment alternatives or other health-related benefits and
services that may be of interest to you.

Fund raising

: We may contact you as part of a fund-raising effort.

Food and Drug Administration (FDA

): We may disclose to the FDA health information relative to adverse
events with respect to product and product defects, or post marketing
surveillance information to enable product recalls, repairs, or
replacement.

Workers compensation

: We may disclose health information to the extent authorized by and
to the extent necessary to comply with laws relating to workers
compensation or other similar programs established by law.

Public health

: As required by law, we may disclose your health information to
public health or legal authorities charged with preventing or
controlling disease, injury, or disability.

Law enforcement

: We may disclose health information for law enforcement purposes as
required by law or in response to a valid subpoena.

Members of the Military

: If you are a member of the military services including the
Commissioned Corps of the United States Public Health Service, Wichita
Child Guidance Center may use or disclose your health information if
necessary to appropriate military command authorities as authorized by
law.

Federal law makes provision for your health information to be released
to an appropriate health oversight agency, public health authority or
attorney, provided that a work force member or business associate
believes in good faith that we have engaged in unlawful conduct or
have otherwise violated professional or clinical standards and are
potentially endangering one or more patients, workers or the public.

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