14650 Detroit Avenue, Suite LL40

Lakewood, OH 44107

(216) 226 2721 FAX (216) 226 2731

Information regarding your health care, including payment for health care, is protected by two federal laws: The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d et seq., 45 C.F.R Parts 160 and 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2. Under these laws, the Center for Interpersonal Development (CID) may not say to a person outside of CID that you attended the program, nor may CID disclose any other protected information except as permitted by federal law.

The Center for Interpersonal Development must obtain your written consent before it can disclose information about you for payment purposes. For example, CID must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before CID can share information for treatment purposes or for health care operations. However, federal law permits CID to disclose information without your written permission;

1. Pursuant to an agreement with a business associate;

2. For research, audit or evaluations;

3. To report a crime committed on CD premises or against CID personnel;

4. To medical personnel in a medical emergency;

5. To appropriate authorities to report suspected child abuse or neglect;

6. As allowed by a court order.

For example, CID can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a business associate agreement in place.

Before CID can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. CID is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. CID will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy (at reasonable cost) your own health information maintained by CID, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in CD’s records, and to request and receive an accounting of disclosures of your health related information made by CID during the six years prior to your request. You also have the right to receive a paper copy of this notice.

Center for Interpersonal Development is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. CID is required by law to abide by the terms of this notice. CID reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains.

You may complain to CID and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated under HIPAA. You may speak directly to the Director of CID and file a report with the Director detailing your concerns. Or you may request information from CID staff on how to file a complaint with the Secretary of the United States Department of Health and Human Services. You will not be retaliated against for filing such a complaint.

Violation of the Confidentiality Law by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.

For further information contact the Executive Director, Director of Clinical Services or the Director of Occupational Services of CID at (216) 226 2721.

April 14, 2003 is the date upon which this notice became effective.

I hereby acknowledge receiving a copy of this notice

Client’s Signature_______________________________________Date________________