NOTICE OF PRIVACY PRACTICES
II. Uses and Disclosures of Protected Health Information Requiring Authorization
III. Uses and Disclosures Not Requiring Consent or Authorization
- Suspected or known child abuse or neglect
- Suspected or known sexual abuse of a child
- Adult and Domestic abuse
- Judicial or administrative proceedings (i.e., you are ordered here by the court)
- Serious threat to health or safety (i.e., threats to others or threat to national security)
IV. Patient’s Rights and Our Duties
- The right to request restrictions on certain uses and disclosures of your protected health information which CIBH may or may not agree to but if so, such restrictions shall apply unless any agreement is changed in writing
- The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want forms mailed to your home address so CIBH will send them to another location of your choosing.
- The right to inspect and copy your protected health information in the designated record and any billing records for as long as protected health information is maintained in the record.
- The right to insert an amendment in your protected health information, although the counselor may deny an improper request and/or respond to any amendment(s) you make to your record of care.
- The right to an accounting of non-authorized disclosures of your protected health information.
- The right to a paper copy of notices/information from CIBH, even if you have previously requested electronic transmission of notices/information.
- The right to revoke your authorization of your protected health information except to the extent that action has already been taken.
You have the right to have oral or written instructions for filing a complaint. The right to file a HIPAA complaint is not time limited. If you need assistance in filing a HIPAA complaint, you may visit the following Health and Human Services website: grievance or want further information, please contact:
If you prefer, you may also submit a written complaint in your own format by either:
Print and mail the completed complaint and consent forms to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
Email to OCRComplaint@hhs.gov