Clear Brook Counseling Professionals

Privacy Notice

This notice describes how medical information about you may be used and disclosed and how you can access the information.

PLEASE REVIEW CAREFULLY
Clear Brook Counseling Professionals, LLC is a private agency that provides social services within the community. Clear Brook Counseling Professionals, LLC provides services for adults and children in the areas of mental health counseling, substance abuse counseling and skill development to address behavioral and mental health needs.
Protecting the privacy of information about your condition and health is a responsibility we take very seriously.
This flyer covers the activities of all services performed by Clear Brook Counseling Professionals, LLC. From this point on, the term health information will be used to identify any information related to mental health counseling or services you receive from Clear Brook Counseling Professionals, LLC.
Uses and Disclosures of Information about Your Health without Your Authorization
Clear Brook Counseling Professionals, LLC partners and contracts with Story County and with the State of Iowa.
To maintain quality services, certain administrative information needs to be shared among contacting agencies. This includes information like your name, address, phone number, health needs and date of birth.
This type of information will be stored in a data bank and used by agencies that provide services to you or where you have applied for services. It should help you and the people who work with you to coordinate the services that you receive. Information about substance abuse, HIV, and mental health information e.g., diagnosis, or what you say to your counselor, physician, or therapist will not be given out without a specific authorization for release of information as required by law.
Following are examples of the types of uses and disclosures of your protected health care information that are permitted without a specific authorization. These examples describe some of the typical types of uses and disclosures that we may make.
Treatment, Payment and Health Care Operations: Your protected health information may be used to coordinate treatment and other services or to provide payment for your health care services. For example, we may talk with your case manager/social worker about which services are best for you. We may also use and disclose your protected health information to support business activities like eligibility determination, coordination of services, quality assessment activities, program evaluation, and other business activities. For example, we may talk to another provider to help determine who will pay for your services.
We may also share your protected health information with business associates that perform various activities on our behalf. They have agreed to protect your privacy as well.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about the services we offer. You may contact our Privacy Officer to request that these materials not be sent to you.
Public Health: As required by law, we may disclose your health information to public health authorities to: prevent injury or disability, or report child/adult abuse or neglect.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit program, other government regulatory programs and civil rights laws.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes, including: (1) legal processes otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on Clear Brook Counseling Professionals, LLC’s premises, and (6) medical emergency (not on Clear Brook Counseling Professionals, LLC’s premises.) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.
Research: We may disclose your protected health 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 protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military and Veterans: If you are a member of the armed forces, we may release information about your health as required by military command authorities.
Persons Involved In Your Health Care: We will communicate with family members whom you designate to help you or who in our judgment need to be involved unless you object. This might include persons who help you with communication barriers, such as language, or hearing problems.
Emergencies: If we are asked to provide protected health information that is necessary to provide emergency treatment, we shall instruct the treatment provider to obtain your authorization as soon as reasonably possible after the delivery of treatment. If they have attempted to obtain your consent but are unable to obtain your consent, we may still disclose your protected health information so they may treat you.
Disaster Relief: To a public or private entity assisting in a disaster relief (e.g. to notify your family about your location, condition, death).
Uses and Disclosures of Information about Your Health with Your Authorization
Other uses and disclosures of information about your health that are not described in this notice or are not otherwise permitted by law will be made only with your written authorization. You may revoke such authorization as described in this notice.
Your Rights Regarding Information About Your Health
You have the following rights regarding the health information we maintain about you, which you may exercise by submitting your request in writing to:
Attention: Jamie Pfantz
Clear Brook Counseling Professionals, LLC
614 Billy Sunday Road, Suite 100
Ames, IA  50010

Right to Revoke Authorizations: You may revoke your authorization that allows us to use or disclose health information that is not otherwise covered by this notice or applicable law in writing at any time except: when the authorization was obtained as a condition of determining eligibility, during the contestable period, or to the extent that we have taken action in reliance on your written authorization. We are unable to take back any disclosures we have already made with your authorization and we may retain documents that may contain information about your health.
Right to Request Restrictions: You have the right to request a restriction of your protected health information for treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care.
Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you request.
Right to Request Confidential Communications: If you could be endangered by our normal communication channels, you have the right to request that we communicate information about your health to you by alternative means or at an alternative location. We will accommodate reasonable requests provided you explain the reason for the request and how or where you should be contacted.
Right to Amend: This means you may request an amendment of your protected health information as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement, which we will review and get back to you. If you have questions about amending your protected health information, please contact our Privacy Officer, Jamie Pfantz at the Clear Brook Counseling Professionals, LLC office at (515) 337-1766.
Right to Request an Accounting: You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.
Right to a Copy of this Notice: You have the right to obtain a copy of this notice at any time. Contact our Privacy Officer at (515) 337-1766.
Our Duties Regarding Information about Your Health
We are required by law to:

  • Maintain the privacy of information about your health.
  • Provide you with this notice of our legal duties and health information privacy practices.
  • Abide by the terms of this notice.

Changes to this Notice
We reserve the right to change the terms of this notice. We reserve the right to apply the changed notice to health information we already have about you, as well as any information we receive in the future. If we make a material change to the terms of this notice, we will mail a revised notice to you.
For More Information or to File a Complaint
If you have questions and would like additional information, you may contact our Privacy Officer, Jamie Pfantz, at (515) 337-1766.
If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer and with the secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint. This notice is effective September 1, 2015.

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