Notice of Privacy Practices

​A Chance To Grow, Inc. 
Notice of Privacy Practices 
Effective Date: January 25, 2023

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 review it carefully. 

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Rights 
  • Get an electronic or paper copy of your medical record
    • We may say “no” to your request, but we’ll tell you why in writing within 60 days. 
  • Ask us to correct your medical record 
    • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say, “yes” to all reasonable requests. 
  • Request confidential communications 
    • You can ask us not to use or share certain health information for treatment, payment, or our operations. 
    • We are not required to agree to your request, and we may say “no” if it would affect your care. 
  • Ask us to limit what we use or share 
    • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. 
    • We will say “yes” unless a law requires us to share that information. 
  • Get a list of those with whom we’ve shared information 
    • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
    • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
    • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. 
    • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. 
    • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. 
  • Choose someone to act for you
    • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 
    • We will make sure the person has this authority and can act for you before we take any action. 
  • File a complaint if you feel your rights are violated 
    • You can complain if you feel we have violated your rights by contacting us using the information on page 1. 
    • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Avenue, S.W., Washington, D.C. 20201
      Or call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. 
    • We will not retaliate against you for filing a complaint. 

Your Choices 
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. 
  • In these cases, you have both the right and choice to tell us to: 
    • Include your information in a hospital directory 
    • Contact you for fundraising efforts 
    • If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.  
  • In these cases we never share your information unless you give us written permission:
    • Share information with your family, close friends, or others involved in your care
    • Share information in a disaster relief situation 
    • Marketing purposes 
    • Sale of your information 
    • Most sharing of psychotherapy notes 
  • In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. 

Our Uses and Other Disclosures 
  • How do we typically use or share your health information?
    • We typically use or share your health information in the following ways. 
  • Treat you 
    • We can use your health information and share it with other professionals who are treating you. (Example: A doctor treating you for an injury asks another doctor about your overall health condition)
  • Run our organization
    • We can use and share your health information to run our practice, improve your care, and contact you when necessary. (Example: We use health information about you to manage your treatment and services.) 
  • Bill for your services 
    • We can use and share your health information to bill and get payment from health plans or other entities. (Example: We give information about you to your health insurance plan so it will pay for your services.)
  • How else can we use or share your health information? 
    • We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
    • For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. 
  • Help with public health and safety issues 
    • We can share health information about you for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medications. 
    • Reporting suspected abuse, neglect, or domestic violence.
    • Preventing or reducing a serious threat to anyone’s health or safety
  • Do Research
    • We can use or share your information for health research. 
  • Comply with the law 
    • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law. 
    • We can share health information about you in response to a court or administrative order, or in response to a subpoena.
  • Work with a medical examiner or funeral director 
  • Respond to organ and tissue donation requests 
  • Address workers’ compensation, law enforcement, and other government requests 
  • Respond to lawsuits and legal actions 

Our Responsibilities 
  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. 
  • We can share health information about you with organ procurement organizations. 
  • We can use or share health information about you: 
    • For workers’ compensation claims 
    • For law enforcement purposes or with a law enforcement official 
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national security, and presidential protective services 

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. 

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.  

Changes to the Terms of This Notice 
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.  

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA) 
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but is not mandatory for me to sign in order to:
  • Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly 
  • Obtain payment from third-party payers
  • Conduct normal health care operations such as quality assessments and physician certifications 

I have been informed by your agency of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. 

If you have any questions about this Notice or would like further information, please contact the Privacy Officer at (612) 789-1236.