Privacy Policy

Marwil&Associates, Inc.

1300 W. Belmont, Chicago, IL 60657

The Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA, requires us to notify you of how your personal health information is used for your medical care and for business and administrative functions. It requires that your information be kept confidential, and that we have your permission to use that information for certain activities outside of this office.

We are committed to keeping your personal information confidential. With your permission, we may use and disclose information for the purposes of treatment, payment and billing, and for various administrative operations. However, we will only release the amount of information necessary for the purpose needed and not any additional information. We may disclose this information in writing, orally, by electronic facsimile or by mail to others.

We may use your personal health information to inform and consult with your physician or (former/future) therapist, confer with and refer to other health care providers, gather data, bill and obtain payment for services from your insurance company and for other similar purposes. There are some situations, where by law, we must provide your personal health information to

others, such as abuse or neglect, law enforcement, judicial and administrative proceedings, health oversight activities, emergency situations, and those required by state or federal law or as required by the Secretary of Health and Human Services.

When passing along information as allowed or required, the following message will be included in any emails, letters, or facsimiles that we may transmit:

This message and any included attachments are intended only for the addressees. The information contained in this message is confidential, private and may constitute proprietary or non-public information under federal and/ or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the intended addressee, please promptly delete or destroy this message and notify the sender of the delivery error by e- mail, letter or facsimile.

The HIPAA requirements give you certain rights as well, including the right NOT to allow us to use this information. You may restrict to whom the information is released if it is not to someone or some entity involving your health care. You have the right to have access to your own records, the right to request changes in the information if you feel it is in error, the right to know to whom information is released, and the right to file a

complaint if you feel your information was used inappropriately.

We ask for your signed permission to use your personal information for these purposes only and for your acknowledgement that you have received this notification and the attached forms. Please review the attached forms regarding your information, your rights, and my responsibilities, sign where indicated, and retain a copy for your records. A copy will also be included in your record.

If you have any questions now or in the future, please let us know. Thank you for your understanding and your cooperation.

Marwil & Associates:

• Jo Marwil, Psy.D. drjo@marwilpsychotherapy.com
• Fawn Cooney,LPC fawn@marwilpsychotherapy.com

Your Information. Your Rights. Our Responsibilities.

Your Rights

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.

You have the right to:

• Get a copy of your paper or electronic medical record.
• Correct your paper or electronic medical record.
• Request confidential communication.
• Ask us to limit the information we share.
• Get a list of those with whom we have shared your information.
• Get a copy of his privacy notice.
• Choose someone to act for you.
• File a complaint if you believe your privacy rights have been violated.

Your choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition.
• Provide disaster relief.
• Provide mental health care.

Our Uses and Disclosures

We may use and share your information as we:

• Treat you.
• Run our organization.
• Bill for services.
• Help with public health and safety issues.
• Do research.
• Comply with the law.
• Respond to organ and tissue donation requests.
• Work with a medical examiner or funeral director.
• Address workers’ compensation, law enforcement, and other government requests.
• Respond to lawsuits and legal actions.

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your medical record.
• Ask us to correct your medical record.
• Request confidential communications.
• Get a list of those with whom we have shared information.
• Get a copy of this privacy notice.
• Choose someone to act for you.
• File a complaint if you feel your rights are violated.

You can ask to see or get an electronic or paper copy of your medical record and other health information that we have about you. Please submit your request to us via email.

We will provide a copy or a summary of your health information, usually within 30 days of your request.

Charges will apply and will be communicated once we receive your request.

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we will tell you why in writing within 60 days.

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests.

You can ask for a list (accounting) of the times that we have shared your health information for six years prior to the date you ask, who we shared it with, and why.

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

We will make sure the person has this authority and can act for you before we take any action.

We include all the disclosures except for those about treatment, payment, and health care operations, and

certain other disclosures (such as any you ask me to make). We will provide one accounting a year for free but will charge a reasonable, cost- based fee if you ask for another one within 12 months.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

You can complain if you feel that we have violated your rights by contacting information below:

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1.877.696.6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Your Choices: For certain health information, you can tell us your choices about what I share. If you have a clear preference for how we share your information in the situations described below, let us know. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

In these cases, we will never share your information unless you give me written permission:

In the case of fundraising:

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation Include your information in a hospital directory Marketing purposes.
• Sale of your information.
• Most sharing of psychotherapy notes.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to your health.

We are required by the State of Illinois to report to the State if you are a danger to yourself for someone else and you are a firearm owner (Public Act 095-0564).
Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know prompting if a breach occurs that may have compromised the privacy
  or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us that we can
  in writing. If you tell us that we can, you may change your mind at any time. Let us know in writing if you change your mind.
• For more information see: www.hhs.gov.ocr/privacy/ hipaa/ understanding/consumers/noticepp.html Changes to the terms of this Notice
  We can change the terms of this notice, and the change will apply to all information that we have about you. The new notice will be available upon request, in my office.

Effective January 1, 2024
This Notice of Privacy Practices applies to the following organizations: Marwil & Associates

• Receipt of Notice of Private Policy Name:

My signature below documents that I have received the Notice of Private Practices from this office and I agree with its contents.

Signature: ______________________________________________

Printed Name:___________________________________________

Date: _________________________________________________

We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell me I can
in writing. If you tell us that we can, you may change

your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov.ocr/privacy/ hipaa/ understanding/consumers/noticepp.html

Changes to the terms of this Notice
We can change the terms of this notice, and the change will apply to all information that we have about you.