Effective Date: April 1, 2004

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Any questions about this notice should be addressed to the Clinical Director, Lova Njuguna, at (520) 882-0090.

Counseling & Consulting Services, (hereinafter referred to as CCS) is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices with respect to protected health information. CCS is required by law to abide by the terms of this notice; however, CCS does reserve the right to change the terms of this notice. CCS is required to follow the terms of the notice currently in effect. Any revisions to this notice will be posted at all sites with the effective date indicated, and paper copies of this notice will be provided upon request.

This notice describes CCS's practice and that of any CCS workforce member who is authorized to enter information in your medical record. Facilities or programs may share medical information for treatment, payment, or CCS operations purposes described in this notice.

This Notice of Privacy Practices describes how CCS may use and disclose your protected health information to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future behavioral health and related health care services.

You will be asked to sign a consent form at time of intake. Once your consent is obtained, your protected health information may be used and disclosed by CCS staff members and others outside our offices who are involved in your care and treatment for the purpose of providing health care services to you. Examples of the types of uses and disclosures that are permitted are given below. These are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

Treatment: CCS may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, CCS would disclose your protected health information to other physicians who may be treating you, to a physician to whom you have been referred, or to any other physician or health care provider who, at the request of your primary physician, becomes involved in your care by providing assistance with your diagnosis or treatment to your primary physician.

Payment: CCS may use and disclose your protected health information to obtain payment for your health care services. This may include the disclosure of medical information to obtain prior authorization, for making a determination of eligibility or coverage, for reviewing services for medical necessity, and for utilization review activities.

Health Care Operations: CCS may use and disclose protected health information about you for internal operations. These uses and disclosures can include quality assessment activities, employee review activities, licensing and accreditation activities, and conducting or arranging for other business activities.

CCS may share your information with third party "business associates" that perform various activities (e.g., records storage) for CCS. Whenever an arrangement between our office and a business associate involves the use or disclosure (or potential use of disclosure) of your protected health information, CCS will have a written agreement that contains the terms that will protect the privacy of your health information.

Appointment Reminders: CCS may use and disclose protected health information to contact you as a reminder that you have an appointment at one of our facilities/programs.

As Required by Law: CCS will disclose protected health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: CCS may use and disclose protected health information about you when necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person.

Health Oversight Activities: CCS may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities could include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Law Enforcement: CCS may disclose protected health information if asked to do so by law enforcement officials: In response to a court order, subpoena, warrant, summons, or similar process. About the victim of a crime if, under certain limited circumstances, CCS is unable to obtain the person's agreement. About criminal conduct at any CCS program/facility, or in emergency situations.

Research: CCS may disclose your protected health information to researchers when their research has been approved by Counseling & Consulting Services, Executive Committee. Such approval ensures that protocols have been established to ensure the privacy of your protected health information.

Abuse or Neglect: CCS may disclose your protected health information to an authority that is authorized by law to receive reports of abuse or neglect (e.g., CPS, APS). In addition, CCS may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to an authorized governmental entity or agency. In this case, the disclosure will be made consistent with the requirements of applicable laws.

You have the following rights regarding protected health information CCS maintains about you:

Right to Inspect and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually this includes medical and billing records but does not include psychotherapy notes.

If you request a copy of your records, CCS may charge a fee for the cost of copying, mailing, or other supplies associated with your request. You will not be allowed to remove your original record.

In certain very limited circumstances, your request to inspect and copy your record may be denied. If this occurs, you can request a review of the denial.

Right to Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask that the information be amended. Your request must be submitted in writing to the Clinical Director. Additionally, you must provide a reason that supports such a request.

If your request is not in writing or does not include a reason to support the request, CCS may deny the request. In addition, CCS may deny the request if you ask for information not compiled by CCS, or information that is not part of the protected health information maintained by CCS. CCS may deny the request if the maintained protected health information is complete and accurate.

Right to an Accounting of Disclosures: You have a right to request a list of disclosures CCS has made of protected health information about you to others, except for purposes of treatment, payment, and operations specified above.

Any request for a list of disclosures must by made in writing to the Clinical Director. Your request must state a time period that cannot be longer than six years and cannot include dates prior to April 1, 2003. Your written request should dictate the form in which you wish to receive this list. The first list requested in a 12 month period will be provided free of charge to you. For any additional lists requested, you will be charged the cost of providing this information to you.

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information CCS would use or disclose about you for treatment, payment, or health care operations. To request restrictions, you must make your request in writing to the Clinical Director. That request must define what information you want to limit, whether to limit use, disclosure, or both, and to whom you want the limits to apply.

CCS is not required to agree to your request. If the request for restriction is granted, CCS will comply with your request unless the information is needed to provide emergency treatment or to meet orders of the court.

Right to Request Confidential Communications: You have the right to request that CCS communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that CCS only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Clinical Director. We will accommodate all reasonable requests.

Right to a Paper Copy of this Notice: You have the right to a paper copy of this privacy notice. You will receive a copy of this privacy notice during the intake process. You may ask us to give you a copy of this privacy notice at any time by requesting a copy from any CCS staff member.

If you believe your privacy rights have been violated, you may contact or submit your complaint in writing to:

Clinical Director, 2430 E. 6th Street, Tucson, AZ. 85719

You can also file a complaint with the Secretary of the Department of Health and Human Services.

The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

Other uses and disclosures of protected health information not covered by this notice or the laws that apply to Counseling & Consulting Services, will be made only with your written permission. If you provide CCS permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, CCS will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that CCS is unable to take back any disclosures already made with your permission and that CCS is required to retain our records of the care that is provided to you.