Counseling, Ltd. Notice of  Privacy Practices

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

This notice was prepared by Counseling Ltd. As a health care provider, we are required by law to maintain the privacy of your protected health information. We are also obligated by law to tell you how protected health information about you may be used and under what circumstances it may be disclosed.

Definition of Protected Health Information - We will use the following definition of Protected Health Information (PHI) in this notice. The definition was developed by the United States Department of Health and Human Services.

Protected Health Information (PHI) is any individually identifiable information about your past, present or future health or condition. PHI includes any information about the provision of health care services to you or the payment for any health care services. Protected health information includes written, spoken or electronically recorded information.

Routine use of your Protected Health Information - We will use your protected health information for routine treatment, payment, and health care operations purposes.

When you begin services here we will ask you to sign a consent form agreeing to receive services from us. By signing the consent form you are giving us your permission to use your PHI for routine treatment, payment or operations purposes.

An example of treatment use of your PHI would be if your clinician receives consultation from a supervisor.

An example of payment use of your PHI would be when we submit data about your care to a health insurer or public funding source so that we can be paid for the services we provided.

One example of operations use of your PHI would be when an administrative staff member conducts a review of your case record to make sure all required items are in the record.

As part of our operations, we may contact you by telephone or letter for the purpose of appointment reminders.

Some of our clients ask to be added to our newsletter mailing list. Our newsletter is mailed periodically to everyone on its list. If you ask to be added to the newsletter mailing list, you will automatically receive occasional fund-raising letters from Counseling Ltd.

Your written permission is required for most other uses of your PHI - Even if you give us written permission to share your PHI with another person or organization, you can later revoke your authorization.

Circumstances where your permission to disclose PHI is not required:

• When required by law:
  a.) We are required to report suspicion of child or elder abuse or neglect;
  b.) We are required to report suspicion of criminal activity occurring on our premises or against a staff member;
  c.) If a client communicates a threat to inflict imminent and serious physical harm to a person or structure we have a duty to protect the potential victim and may need to report to the police or warn the potential victim;
  d.) We are required to comply with a court order.
• During a medical emergency we are permitted to disclose PHI without your consent; we will make an attempt to get your consent during or soon after the emergency;
• If requested by the Ohio Legal Rights Service;
• To the coroner in order to determine cause of death or to identify a deceased client;
• To the executor or administrator of a deceased client's estate if our information is necessary to administer the estate (a legal document must indicate that the person requesting the information is the executor).
• If an attorney representing the Franklin County ADAMH Board requests information for commitment proceedings.
• For operations purposes, including audits and evaluations conducted by the Ohio Department of Mental Health, the Ohio Department of Drug and Alcohol Addiction Services and the Franklin County ADAMH Board.

Your rights regarding your protected health information:

A. To request restrictions on uses and disclosures - You have the right to ask that we restrict how we use or disclose your protected health information when we carry out routine treatment, payment or operations functions. We will consider your request, but we are not legally bound to agree with the restrictions you have requested.

B. To choose how we contact you - You have the right to request we contact you by alternative means or at alternative locations. Your request must be made in writing. We will refuse your request only if we cannot reasonably accommodate it. We are not able to communicate with you through electronic mail (e-mail).

C. To inspect and copy your protected health information - You have the right to inspect and copy your protected health information. Requests must be made in writing and will be responded to within 30 days. If we deny your request, based on documented reasons, we will give you the reasons for the denial in writing and explain your right to have the denial reviewed. If you request a copy of your protected health information, a reasonable fee for copying may be imposed, depending on the amount of copying needed. It is our practice to charge for copies of all items except the initial and long assessments; treatment plan; medication sheet; and termination summary.

D. To amend your protected health information - You have the right to request that we amend your protected health information. Please put your request in writing, specifying any changes you feel are necessary. We will respond to your request within 30 days.

E. To request an accounting of certain disclosures - You have the right to ask for a description of disclosures we have made of your protected health information. This right is subject to certain legal restrictions.

F. To have a copy of this notice - Because you have a right to have a copy of this notice, this is yours to keep.

Additional duties required of Counseling Ltd. - We are required to follow the privacy practices described in this notice. We do, however, reserve the right to change the terms of this notice at any time. If we do make changes to this notice, the changes will affect all protected health information maintained by Counseling Ltd.

If we revise the Notice of Privacy Practices, we will notify you by posting the revised notice at our offices and on our web site. If you receive services at a location other than our offices, your clinician will provide you with a copy of the revised notice. You are welcome to keep a copy of the revised notice.

If you receive services in our offices, you may request a paper copy of the revised notice by asking the receptionist or your clinician.

Complaints - If you think your privacy rights have been violated, you may file a complaint with the contact person listed in the section below. You may also file a written complaint, on paper or electronically, with the Secretary of the U.S. Department of Health and Human Services. If you want to file a formal grievance please follow the grievance procedures described in your Client Rights statement.

We will take no retaliatory action against you if you make a complaint.

Counseling Ltd- For additional information about this notice, please call or write:
Privacy Notice Contact Person
Counseling Ltd

4488 W. Broad St

Suite C

Columbus, Ohio 43228

614-870-6670

Effective Date - This notice was effective  January 10,2011.