Privacy Policy
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION
PLEASE REVIEW THIS NOTICE CAREFULLY.
When we refer to “you” or “your” in this Notice we refer to the person or persons receiving the services provided by Empowerment Within LLC. When we refer to disclosures of information to “you”, we mean disclosures to adults or children, the parent of the children, guardian or other person legally authorized to receive information about the person or persons receiving services from Empowerment Within LLC.
Who follows this Notice:
This Notice applies to all protected health information (PHI) maintained by Empowerment Within LLC for services provided at any office of Live Resilient or services provided at non-office locations by any employee of Empowerment Within LLC in the course of their employment. If you have any questions after reading this Notice, please contact the Empowerment Within LLC Privacy Officer.
Each time you receive services from Empowerment Within LLC, a record of the services provided is created. Typically this record could contain information about the type of service you have received, the dates of service and the results of the service provided. At times this will include the reason you have come to Empowerment Within LLC for service and the agreed upon goals of the service provided.
This Notice applies to all of the records containing PHI created as a result of services provided by Empowerment Within LLC.
Our Pledge to Protect Your Health Information: We are required by law to maintain the privacy of your PHI and provide you with a description of our privacy practices. We will abide by the terms of this Notice.
How We May Use and Share Your Health Information With Others
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. For example, a worker or therapist may use PHI about you or your child from a clinic record to determine which treatment option, such as family or individual therapy, best addresses your needs. Your worker or therapist may discuss information found in your record with our consultants, a colleague or their supervisor to assist in treatment planning for you or your child.
For Payment: We may use and disclose PHI to send bills and collect payment from you, your insurance company, or other payors, such as governmental agencies, for the treatment or other related services you receive from Empowerment Within LLC, so Empowerment Within LLC can receive payment for the treatment services provided to you. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing and sending claims to your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
For Health Care Operations: We may disclose PHI about you for business operations of Empowerment Within LLC. These uses and disclosures are necessary for Empowerment Within LLC to provide quality care and cost-effective services. The operations where we may need to disclose PHI includes, but is not limited to, quality assessment activities, employee review activities, and licensing activities. For example, we may share your PHI with third parties that perform various business activities (such as billing or typing services). We will require these third parties to have a contract with us that requires them to safeguard the privacy of your PHI. Quality assessment activities may include evaluating the performance of your therapist or examining the effectiveness of treatment provided to you when compared to patients in similar situations.
Future Communications: We may use your name, address and telephone number to contact you to provide newsletters, information about programs or other services we offer.
Appointments: We may use your PHI for the purpose of sending to you appointment reminders through the mail or by telephone. Messages left for you will not contain specific health information.
Required or Permitted by Law: Empowerment Within LLC is required by law to disclose your PHI in certain circumstances:
For public health oversight activities
To facilitate the functions of federal or state governmental agencies
To report suspected elder or child abuse to law enforcement agencies responsible to investigate or prosecute abuse
In response to a valid court order
To the Department of Health and Family Services, a protection or advocacy agency, or law enforcement authorities investigating abuse, neglect, physical injury, death or violent crimes
To your court-appointed guardian or an agent appointed by you under a health care power of attorney
Prison officials if you are in custody
Worker’s Compensation officials if your condition is work-related
If necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public
When sharing PHI with others outside of Empowerment Within LLC, we share only what is reasonably necessary unless we are sharing PHI to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the PHI that you or the law requires
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding your PHI we maintain. To exercise any of the rights discussed in the remainder of this section, please contact the Privacy Officer for Empowerment Within LLC: 155 E Capitol Dr Hartland, WI 53029.
Right to Request Restrictions: You have the right to request certain restrictions of use and disclosure of your PHI by Live Resilient for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care or the payment for your care. Empowerment Within LLC is not required to agree to restrict the use and disclosure of your PHI. A request for restriction must be made in writing using the form available from the Privacy Officer.
Right to Inspect and Copy: With a few exceptions you have the right to inspect and receive a copy of your PHI. Should you wish to review or copy your PHI you should make a request using the form available from the Privacy Officer. We will arrange for your therapist or another health professional in our clinic to review the PHI with you in our office or to copy the information requested. We may charge you a reasonable fee if you want a copy of your PHI.
Right to Amend or Correct Your Record: If you feel the PHI we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by Empowerment Within LLC. Requests for amendment or correction should be made by submitting a form requesting amendment or correction available from the Privacy Officer. We will respond to your request within 60 days after you submit the form. We are not required to agree to the amendment.
Right to an Accounting of Disclosures: You have a right to request an accounting for disclosures. This is a list of those people with whom Empowerment Within LLC may have shared your PHI, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. We may charge you a reasonable fee if you request more than one accounting for disclosures in any 12-month period. Requests for an accounting of disclosures should be made by submitting a form requesting an accounting of disclosures to the Privacy Officer. This form is available from the Privacy Officer. We will respond to your request within 60 days after you submit the request.
Right to Request Confidential Communications: You have the right to ask that we communicate your PHI to you in a certain way or a certain location. For example, you can request that we contact you only at work or by mail. We will accommodate reasonable requests.
Right to Revoke Authorization: Uses and disclosures of PHI not covered by this Notice or the laws that apply to Empowerment Within LLC will be made only with your authorization. If you authorize Empowerment Within LLC to use or disclose your PHI, you may revoke that authorization in writing at any time. We are unable to reverse any disclosures we have made previously with your authorization. To revoke an authorization please contact your therapist or the clinic where you receive services.
Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with Empowerment Within LLC, contact the Privacy Officer. All complaints must be made in writing. The Privacy Officer will assist you in filing your complaint. Filing a complaint will not affect your care.
We reserve the right to revise or change this Notice. Each time you sign a consent for treatment at a site covered by this Notice we will provide a copy of this Notice in effect at that time.
Effective Date: Jan 8, 2019
How to Contact Us
Empowerment Within LLC: 262-349-1299
Secretary of Department of Health and Human Services: (877) 696-6775