NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR
CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW THIS INFORMATION CAREFULLY
Parent-Child Services Group, Inc. (PCSG) is required by law to maintain
the privacy of all medical information within its organization; provide
this notice of privacy practices to all clients; inform clients of our
legal obligations; and advise clients of additional rights concerning
their medical information. PCSG must follow the privacy practices
contained in this notice from its effective date of April 14, 2003, and
continue to do so until this notice is changed or replaced.
PCSG reserves the right to change our privacy practices and the terms of
this notice at any time, provided applicable law permits the changes. Any
changes made in these privacy practices will be effective for all medical
information that is maintained including medical information created or
received before the changes were made. All clients will be notified of any
changes by receiving a new notice of privacy practices.
You may request a copy of this notice of privacy practices at any time by
contacting PCSG at 1225 E. Weisgarber Road, Suite 180 South, Knoxville, TN
WHO IS COVERED BY THIS NOTICE:
This notice describes the practices of PCSG employees for any sites and
locations. For any student observers, a confidentiality notice will be
signed by the student and reasonable efforts will be made to inform you of
their visit to our facilities. All student employees sign confidentiality
notices and are advised of confidentiality policies.
USES AND DISCLOSURES OF MEDICAL INFORMATION:
Your medical information may be used and disclosed for treatment, payment,
and health care operations, for example:
TREATMENT: Your medical information may be disclosed to a doctor or
hospital that asks for it to provide treatment to you. Departments or
therapists within PCSG may share information with one another to improve
recommendations for your child’s care.
PAYMENT: Your medical information may be used or disclosed to
insurers or contract agencies to pay claims for services provided to you
by therapists within PCSG’s facilities.
APPOINTMENT REMINDERS / ROUTINE COMMUNICATIONS: Unless otherwise
notified by you in writing, PCSG may contact you for appointment
information or other necessary communications at any of the numbers or
addresses provided by you and contained within our files.
HEALTH CARE OPERATIONS: Your medical information may be used and
disclosed for routine operations such as to determine insurance coverage
for services, to conduct quality assessment and improvement activities, to
engage in care coordination or case management, to pursue Right of
Recovery and Reimbursement/Subrogation, for accreditation, for conducting
and arranging legal services, for accounting purposes, for contract typing
of PCSG reports etc.
AUTHORIZATIONS: You may provide written authorization to use your
medical information or to disclose it to anyone for any purpose. You may
revoke an authorization for release of information in writing at any time
revocation will not affect any use or disclosure permitted by your
authorization while it was in effect. Unless you give written
authorization, we cannot use or disclose your medical information for any
reason except those described in this notice.
VIDEOTAPING / PHOTOGRAPHY: Parent-Child Services Group, Inc.
therapists may videotape or photograph your child in the course of
providing therapy. These photographs or videotapes may be used for the
purpose of preparing personally-identifiable therapy materials (e.g.,
schedules, task boards) and to monitor your child’s progress. These tapes
or photographs will not be shared with anyone without your signed release
except as indicated in other sections of this summary.
USE OF PCSG LIBRARY FACILITIES: If you choose to use the library
facilities at PCSG, your name may be added to a check-out card which may
be viewed by others in the course of checking out materials.
PERSONAL REPRESENTATIVE: Your medical information may be disclosed
to a family member, friend or other person to the extent necessary to help
with your health care or with payment for your health care but only if you
agree we may do so, as described in the Individual Rights section of this
MARKETING: Your medical information will not be used for marketing
without your signed consent. Typical requests for use of your information
would be for use of comments on PCSG’s website (if you have completed a
form requesting these comments) or in brochures or other documents created
to demonstrate satisfaction of services.
RESEARCH: Your medical information may be used or disclosed for
research purposes in limited circumstances. This research information will
not contain any personally-identifiable names or addresses but may be
summarized in the form of cumulative test scores or demographics.
AS REQUIRED BY LAW: Your medical information may be used or
disclosed as required by state or federal law. For example, medical
information must be disclosed to the U.S. Department of Health and Human
Services upon request for purposes of determining compliance with federal
privacy laws. Medical information may be disclosed when required by
workers' compensation or similar laws; to a government agency authorized
to oversee the health care system or government programs or its
contractors; and to public health authorities for public health purposes.
COURT OR ADMINISTRATIVE ORDER: Medical information may be disclosed
in response to a court or administrative order, subpoena, discovery
request, or other lawful process, under certain circumstances. Under
limited circumstances (i.e. court order, warrant, or grand jury subpoena),
medical information may be disclosed to law enforcement officials. In
addition, medical information may be disclosed to law enforcement
officials concerning a suspect, fugitive, material witness, crime victim
or missing person. Medical information may be disclosed to law enforcement
officials or correctional institution regarding an inmate or other person
in lawful custody, in certain circumstances.
VICTIM OF ABUSE: Medical information may be released to appropriate
authorities under reasonable assumption that you or your child are
possible victims of abuse, neglect or domestic violence or the possible
victim of other crimes. Medical information may be released to the extent
necessary to avert a serious threat to your or your child’s health or
safety or to the health or safety of others. Medical information may be
disclosed when necessary to assist law enforcement officials to capture an
individual who has admitted to participation in a crime or has escaped
from lawful custody.
MILITARY AUTHORITIES: Medical information of Armed Forces personnel
may be disclosed to Military authorities under certain circumstances.
Medical information may be disclosed to authorized federal officials as
required for lawful intelligence, counterintelligence, and other national
You have the right to look at or get copies of your medical information,
with limited exceptions. You may request a format other than photocopies,
which will be used unless the company cannot practicably do so. You must
make the request in writing to obtain access to your medical information.
You may obtain a form to request access by using the contact information
at the end of this notice or you may send us a letter requesting access to
the address located at the end of this notice. If you request copies
amounting to more than 10 pages, there will be a charge
of $.25 per page, $10 per hour for staff time to copy your medical
information, and postage if you want the copies mailed to you. If you
request an alternative format, the charge will be cost-based for providing
your medical information in that format. If you prefer, we will prepare a
summary or explanation of your medical information for an hourly fee
(based on current hourly therapy rates). For a more detailed explanation
of the fee structure, please use the information at the end of this notice
to contact our office.
You have the right to receive an accounting of the disclosures of your
medical information by our company or by a business associate of our
company. This accounting will list each disclosure that was made of your
medical information for any reason other than treatment, payment, health
care operations and certain other activities since April 14, 2003. This
accounting will include the date the disclosure was made, the name of the
person or entity the disclosure was made to, a description of the medical
information disclosed, the reason for the disclosure, and certain other
information. If you request an accounting more than once in a 12-month
period, there may be a reasonable cost-based charge for responding to
these additional requests. For a more detailed explanation of the fee
structure, please use the information at the end of this notice to contact
You have the right to request restrictions on the company's use or
disclosure of your medical information. The company is not required to
agree to these additional requests, but if in agreement, the company will
honor the agreement, except in an emergency. Any agreement to restrictions
on the use and disclosure of your medical information must be in writing
and signed by a person authorized to make such an agreement on behalf of
the company. The company will not be bound unless the agreement is so
memorialized in writing.
You have the right to request confidential communications about your
medical information by alternative means or alternative locations. You
must inform the company that confidential communication by alternative
means or to alternative location is required to avoid endangering you. You
must make your request in writing and you must state that the information
could endanger you if it is not communicated by the alternative means or
to the alternative location requested. The company must accommodate the
request if it is reasonable, specifies the alternative means or location,
and continues to permit use to collect payment from you or your insurer
under your health plan.
You have the right to request that the company amend your medical
information, typically history information contained in reports. Your
request must be in writing and it must explain why the information should
be amended. The company may deny your request if the medical information
you seek to amend was not created by our company or for certain other
reasons. Interpretation of scores or analysis of behaviors by the
therapists are not amendable in the record. If your request for amendment
is denied, the company will provide a written explanation of the denial.
You may respond with a statement of disagreement to be appended to the
information you wanted amended. If the company accepts your request to
amend the information, the company will make reasonable efforts to inform
others, including the people you name, of the amendment and to include the
changes in any future disclosures of that information.
If you received this notice on our web site or by electronic mail
(e-mail), you are entitled to receive this notice in written form as well.
To obtain this notice in written form, please use the information at the
end of this notice to contact our office.
If you want more information concerning the companies' privacy practices
or have questions or concerns, please contact us as indicated below.
If you are concerned that the company has violated your privacy rights, or
you disagree with a decision made about access to your medical
information, or in response to a request you made to amend or restrict the
use or disclosure of your medical information or to have us communicate
with you by alternative means or at alternative locations, you may
complain to us using the contact information below. You may also submit a
written complaint to the U.S. Department of Health and Human Services. The
address to file a complaint with the U.S. Department of Health and Human
Services will be provided upon request.
Parent-Child Services Group, Inc. supports your right to protect the
privacy of your medical information. There will be no retaliation in any
way if you choose to file a complaint with us or with the U.S. Department
of Health and Human Services.
Lynne F. Harmon, M.A., CCC-SLP,
Parent-Child Services Group, Inc.
1225 E. Weisgarber Road, Suite 180 South
Knoxville, TN 37909
(865) 584-6607 FAX
© 2000 Parent-Child Services Group, Inc.