HIPAA NOTICE OF PRIVACY PRACTICES

WHO WILL FOLLOW THIS NOTICE

This Notice of Privacy Practices describes the practices of all Independence Center staff, any volunteers that we allow to work in our facilities, and any business associates affiliated with the Independence Center.

OUR COMMITMENT TO YOUR PROTECTED HEALTHINFORMATION

We understand that medical information about you and your health is personal and confidential, and we are committed to protecting that information. We create a record of each and every one of the services that you receive from the Independence Center. We need this record to provide you with quality care and to comply with legal requirements. All health records created and maintained by theIndependence Center are subject to these regulations.

This Notice is required to inform you of the ways in which we may use and disclose protected health information about you. This Notice also describes your rights and certain obligations we have regarding the use and disclosure of your protected health information.

OUR LEGAL DUTY

We are required by law to maintain the privacy of your protected health information. We are required by law to provide this Notice about our legal duties and your rights regarding your protected health information. We are required by law to abide by the privacy practices described in this Notice while it is currently in effect. We do reserve the right to make changes to our privacy practices and the terms of this Notice at any time, provided that the changes are permitted by applicable law. If we should make any significant changes to our privacy practices, we will change this Notice and post it prior to the changes taking effect. We will also make any revised Notices available upon request. We reserve the right to make changes to our privacy practices and the terms of this Notice effective for all protected health information that we created or received prior to issuing a revised notice.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The Independence Center will not disclose your protected health information to anyone, except with your authorization or as otherwise permitted or required by law. The following categories describe different ways that we may use and disclose protected health information. Not every use or disclosure in a category will be listed. In some instances the disclosure of protected health information may be further restricted by applicable state or federal laws. However, all means of use and disclosure of protected health information will fall within one of the categories:

Treatment

We may use protected health information about you to provide, coordinate, or manage your treatment or services. For example, we may disclose protected health information about you to any or all Independence Center personnel who are involved in your treatment. These uses and disclosures are necessary to provide quality care and to evaluate the performance of our staff.

Payment

We may use and disclose protected health information about you sothat the treatment and services youreceive may be billedto and payment collected from you, an insurance company, or athird party. For example, we may use and disclose protected health information about you to the Department of Health and Human Services toreceive Medicaid reimbursement for services renderedto you.

Health Care Operations

We may use and disclose protected health information about you to operate our facility. For example, we may disclose protected health information about you to meet the requirements of state or federalgrants awarded to the Independence Center. We may use or disclose protected health information about you to meet insurance requirements as well.

Covered Entity Participates with Other Behavioral Health Services Agencies

Covered Entity participates with other behavioral health services agencies (each, a “Participating Covered Entity”) inthe IPA Network established by Illinois Health Practice Alliance, LLC (“Company”). Through Company, the Participating Covered Entities have formed one or more organized systems of health care in which the Participating Covered Entities participate in joint quality assurance activities, and/or share financial risk for the delivery of health care with other Participating Covered Entities, and as such qualify to participate in an Organized Health Care Arrangement (“OHCA”), as defined by the Privacy Rule. As OHCA participants, all Participating Covered Entities may share the PHI of their patients for the Treatment, Payment and Health Care Operations purposes of all of the OHCA participants.

Individuals Involved In YourCare or Payment for Your Care

We will discussyour treatment with any individualthat you indicate providedthat there is written authorization from you.

Appointment Reminders

We may use and disclose protected health information about you to contact you as a reminder that you have an appointment for treatment. You may request the use of an alternative address or method of contact for communications involving protected health information.

Fundraising

We may contact you toraise funds for the Independence Center if you provide written authorizationto do so.

Research

We may use and disclose protected health information about you for research purposes. We will obtainyour written authorization if the researcher will have access to protected health information.

As Required By Law

We will disclose protected health information about you ifrequired to do so by federal, state or local laws.

To Avert a Serious Threat to Health or Safety

We may use and disclose protected health information about you if such disclosure is necessary to prevent a serious threat to your health or safety orthe health and safety of others as authorized by applicable federal or state laws.

SPECIAL SITUATIONS Public Health Activities

We may use or disclose protected health information about you for public health activities as authorized by applicable federal or state laws.

Victims of Abuse, Neglect, or Domestic Violence

We may disclose protected health information about you to the Department on Aging if you are sixty years of age or older andthere is sufficient evidence that you are the victim of abuse, neglect, or domestic violence within the past twelve months.

Health Oversight Activities

We may disclose protected information about you to a health oversight agency for activities authorized by the law. Health oversight agencies include government agencies that oversee health care administration and certifying organizations. These oversight activities may include audits, investigations, inspections and certification.

Judicial Proceedings

We may disclose protected health information about you inresponse to acourt or administrative order if you are involved in a lawsuit or dispute. We may disclose protected health information about you in response to subpoenas, discovery request or other lawful process.

Specific LawEnforcement Activities

We may disclose protected health informationrequested by a law enforcement official under the following circumstances when permitted by state or federal law:

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 acrime if, under certain limited circumstances, we are unable to obtain the person’s agreement

About a death we believe may be the result of criminal conduct

In emergency circumstancesto report a crime, the location ofthe crime or victims or the identity, description or location of the person whocommitted the crime

About crimes that occur on our premises

Workers’ Compensation

We may disclose protected health information about you to comply with workers’ compensation laws and other similar legally established programs.

Coronersand Medical Examiners

We may disclose protected health information about youto acoroner or medicalexaminer in response to an authorized request.

National Security and Intelligence Activities

We may disclose protected health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Inmates

We may disclose protected health information about you ifyou are an inmate of a correctional institution or inthe custody of a law enforcement official to the correctional institution or lawenforcement official. This disclosure would be necessary for the institution to provide you with proper health care andto protect your health and safety and the health and safety of others and the institution.

YOUR RIGHTS

You have the right to request restrictions on certain uses and disclosures of your protected health information.

You may request that we not use or disclose any part ofyour protected health information for purposes of treatment, payment or health care operations. You may also request that we not disclose any part of your protected health information to family members or other representatives involved in your care. Requested restrictions must be made in writing tothe Privacy Officer listed below. We will make reasonable efforts to honor all requests, however we are not required to agree to a requested restriction.

You have the right to receive confidential communications of protected health information. You may request toreceive confidential communications from us regarding your protected health information via electronic copy, paper copy, or alternative means or at an alternative location. We will accommodate all reasonable requests. All requests need to be made to the Privacy Officer listed below. We may charge areasonable, cost‐based fee.

You have the right to inspect and copy your protected health information. You may inspect and obtain a copy of any protected health information about you that we generate for as long as we maintain the information so long as access tothat information is not prohibited by state or federal law. According to federal law, you may not inspect or copy psychotherapy notes, informationcompiled in reasonable anticipation of, or use in, acivil, criminal, or administrative action or proceeding, and protected health information that law prohibits access to.

You have the right to amend yourprotected health information. You may request an amendment of protected health information about you as long as we maintain the information. Arequest for amendment must be made in writing and submittedto the Privacy Officer. The written request must include a reason that supports your request. We may deny your request if it exceeds statutory guidelines.

You have a right to receive an accounting ofdisclosures we have made of yourprotected health information. You may request a list of disclosures we made of protected health information about you. You must submit your request in writing to the Privacy Officer listed below. The request must state atime period which may not exceed six years in length or include dates prior to April14, 2003. We will provide you with an accounting of all disclosures except for those made for treatment, payment or health care operations purposes, and certain other disclosures (such as any you requested we make). We will provide you with one accounting per year for free, but we will charge areasonable, cost‐ based fee for each additional accounting requested within a12 month period.

You have the right to obtain a paper copy of this Notice at any time upon request.

You may request a paper copy of this Notice at any time, even if you agreed toreceive the Notice electronically. We will provide you with a paper copy promptly.

You have the right to choosesomeoneto act on your behalf. If you have given someone medical power of attorney or if someone is your legalguardian, that person can exercise your rights and make choices about your health information. We willensure the person has the authority and can act onyour behalf before we take any action.

CHANGES TO THIS NOTICE

We reserve theright to make changesto this Notice at any time. This Notice is not a legalcontract. We reserve the right to make the revised or changed Notice effective for protected health information that we create or obtain about you prior to or after any changestake effect. We will post a copy of the current Notice at each of our properties and on our website. A copy of the current Notice will be offeredto all new members joining our program, and will be available to all existing members upon request.

Filea Complaint if You Believe your Rights have been Violated. 

You may complain if you feel that we have violated your rights by contacting Independence Center’s Privacy Officer at the contact information available at the end of this Notice. To file a complaint with the Independence Center, you must submit the complaint in writing and address it tothe Privacy Officer. You may also file a complaint with the U.S. Department of Health and Human Services Office for CivilRights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1‐877‐696‐6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint with the Office of Civil Rights or us.

QUESTIONS AND COMPLAINTS

If you have any questions or complaints about our privacy practices, please contact us at the number below.

WHO TO CONTACTFOR MORE INFORMATION

PRIVACY OFFICER Independence Center 2025 Washington St. Waukegan, IL 60085 (847)360‐1020 privacy@icwaukegan.org

OTHER USES OF PROTECTED HEALTH INFORMATION

Other uses and disclosures of protected health information about you not covered by this Notice, or not covered by federal or state law, will be made only with your written authorization. If you provide us with authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. Ifyou revoke your authorization, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. We will not be able to take back any disclosures we have already made withyour authorization. We are requiredto retain records of services we provided for you for at least five years after you have your records closed with us.