Samaritan Counseling Center

1803 Oregon Pike Lancaster, PA 17601 717-560-9969 FAX 717-560-9553

**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.**

Notice

Effective date: 05/24/02

To Clients of the Samaritan Counseling Center:

The Samaritan Counseling Center (SCC) is committed to providing the highest level of service possible to our clients as well as to abiding by federal, state and local law. Confidentiality between SCC and clients, is necessary to develop the trust and confidence important for therapeutic intervention.

With your Consent, certain Protected Health Information (PHI) may be disclosed for the purpose of carrying out treatment, payment, or health care operations on your behalf. SCC will disclose only the minimum amount of information required for these purposes.

PHI that may be disclosed: Name, Address, Telephone Number, Social Security Number

Past, present, or future physical or mental health or condition, i.e., diagnosis

Dates and times of sessions

Treatment provided and progress or outcome

Past, present, or future payment for the provision of health care services

For example, PHI may be disclosed to staff of SCC in the course of professional supervision to ensure appropriate and quality treatment. PHI may be disclosed to your health insurance company to ensure reimbursement for treatment. Additionally, PHI may be disclosed to the Samaritan Institute for accreditation purposes.

PHI may be disclosed to appropriate personnel to provide you with appointment confirmation. Also, with your Consent, your name, address and phone number may be used to develop a mailing list so you may receive SCC Newsletters, fundraising information, or materials about other related benefits and services that may be of interest.

PHI may be disclosed without your consent: a) in the event of an emergency, and after attempts have been made to contact you; b) in the event that you might pose a threat to yourself or society, c) in the event that it is required by federal, state or local law.

Other uses or disclosures of PHI will be made only after written Authorization has been obtained from you. You may revoke authorization, in writing, at any time, except to the extent that the SCC has already acted on the authorization.

In reference to PHI, you have the right:

1. To request restrictions on certain uses and disclosures of PHI, although the SCC is not required to agree to your requested restrictions.

2. To receive confidential communications of PHI;

3. To inspect and copy PHI;

4. To amend PHI;

5. To obtain a paper copy of this Notice from SCC, upon request.

SCC is required by law:

1. To maintain the privacy of PHI and provide you with this Notice of its legal duties and privacy practices with respect to PHI;

2. To abide by the terms of the Notice currently in effect;

3. To provide a revised Notice—in the event that SCC changes its privacy practices, which practices will apply to all PHI maintained by SCC—by placing paper copies of the revised Notice in the reception and waiting areas, as well as in individual offices, for a period of at least two months following the date of revision

You may enter a complaint to SCC or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. A complaint may be filed with the SCC by contacting our Privacy Officer in writing. The Privacy Officer will respond to your complaint, in writing, within two weeks of receiving your complaint. The SCC will not retaliate against any person for filing a complaint.

For questions concerning this Notice, please contact the SCC’s Privacy Officer by phone at 717-560-9969.

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