925 Westview Drive, Rock Valley, IA 51247
These evaluation and referral services are offered to you on a confidential basis in accordance with federal regulations (42 CFR, Part 2) and the federal Health Insurance Portability and Accountability Act of 1996.
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.
If you have any questions about this Notice please contact: our Privacy Officer who is
Amanda Ten Napel, M.S., LMFT
This Notice of Privacy Practice describes how we may use and disclose your protected health information to carry out EAP assessment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by, if applicable, accessing our Website, connectionseap.com, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, treatment goals, prognosis and a plan for future care or services. This information, often referred to as your health or medical record, serves as a:
• basis for planning your care and services
• means of communication for the health professionals who contribute to your care
• legal document describing the care you received
• means by which you or a third-party payer can verify that services billed were actually provided
• source of data for medical research
• source of information for public health officials charged with improving the health of the nation
• source of data for facility planning and marketing
• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
• a tool in educating health care professionals
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
• make more informed decisions when authorizing disclosure to others
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:
• request a restriction on certain uses and disclosures of your information
• obtain a paper copy of the notice of information practices upon request
• inspect and obtain a copy of your health record
• amend your health record
• obtain an accounting of disclosures of your health information
• request communications of your health information by alternative means or at alternative locations
• revoke your authorization to use or disclose health information except to the extent that action has already been taken
This organization is required to:
• maintain the privacy of your health information
• provide you with a 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
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We will not use or disclose your health information without your consent/authorization, except as described in this notice.
If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. You may contact our Privacy Officer, Amanda Ten Napel, M.S., LMFT at:
800-779-6125 or e-mail: [email protected] for further information about the complaint process.
We will use your health information for future care recommendations.
For example, we may use clinical information regarding your concerns to make the most appropriate match for your care. We may use your information to assist you in finding the most appropriate level of care for your concern.
We will use your health information for regular health operations.
Members of our 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.
Contracted independent healthcare providers: There are some services provided in our organization through contracts with independent providers. We may disclose your health information to a contracted provider so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the contracted provider to certify that they also comply with the legally required privacy practices.
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 in an emergency situation.
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.
Coroners/medical examiners: We may disclose health information to coroners/medical examiners consistent with applicable law to carry out their duties.
Marketing: We may contact you to provide appointment reminders.
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/court order.
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 workforce member or contracted provider 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.
This notice was published and becomes effective on April 14, 2003.
I, _______________________________, acknowledge that I have received a copy of Connections Inc Employee Assistance Program (EAP) Notice of Privacy Practices which explains the way in which my Protected Health Information may be used and disclosed by Connections Inc EAP and explains my rights with respect to my Protected Health Information. I understand that Connections Inc EAP has the right to revise any of these privacy practices and amend the Notice of Privacy Practices. I have been informed that in the event Connections Inc EAP has revised these practices, a revised Notice will be posted on the Website and I may request a copy. If I wish to discuss the Notice I may contact Connections Inc EAP Privacy Officer, Amanda Ten Napel, M.S., LMFT. at 925 Westview Drive, Rock Valley, IA 51247 or by phone at
800-779-6125 or e-mail [email protected].
Signed:_________________________________________ Date:____________
Witness:________________________________________ Date:____________