Center Associates Your Choices

OUR MISSION
For certain health information, you can tell us your
choices about what we share. If you have a clear
preference for how we share your information in Center
Associates
the situations described below, talk to us. Tell us
To provide quality services focused on what you want us to do, and we will follow your
meeting the mental health needs of instructions.
individuals and the community.

OUR SERVICES
• Outpatient psychotherapy and counseling
In these cases, you have both the right and
choice to tell us to:
• Share information with your family, close friends,
HIPAA Privacy Notice
or others involved in your care
services is a dynamic process in which a • Share information in a disaster relief situation
therapist uses professional skills, knowledge, Effective June 1, 2014
• Include your information in a hospital directory
and training to help individuals take
If you are not able to tell us your preference, for
charge of their lives, and resolve their issues
and problems. Psychotherapy services example if you are unconscious, we may go
may be individual, group, or family, and ahead and share your information if we believe it
are provided by a person meeting the is in your best interest. We may also share your
criteria of a mental health professional, or information when needed to lessen a serious and
imminent threat to health or safety.
an intern working on a master’s degree in
a mental health field who is directly
In these cases we never share your information
T his notice describes how
supervised by a mental health professional.
Medication management is offered to
individuals needing psychotropic
unless you give us written permission:
• Marketing purposes health information about you
interventions. • Sale of your information

• Evaluation services include screening,

• Most sharing of psychotherapy notes may be used and disclosed,
diagnosis, and assessment of individual In the case of fundraising:
and family functioning needs, abilities, and
disabilities, and determining current status a
• We may contact you for fundraising
efforts, but you can tell us not to
and how you can get access
and functioning in the areas of living,
learning, working, and socializing.
b
Center Associates
contact you again.
to this information according to
• Emergency/Crisis services provide a
focused assessment and rapid stabilization
3809 South Center Street
Marshalltown, IA 50158
the Health Insurance Portability
of acute symptoms of mental illness or (641) 752-1585
emotional distress, and are available by
phone or face-to-face, on a 24-hour basis.
1309 South Broadway
and Accountability Act of 1996
The clinical assessment and
psychotherapeutic services are provided
by a person who has training in emergency
Toledo, IA 52342
(641) 484-5234
(HIPAA).
services and who is a mental health
professional, at least by telephone. After Hours Emergency Number:
Services are provided by a person who (641) 752-8467
holds a master’s degree in a mental health
field.
www.centerassoc.com
 Your Rights Get a list of those with whom we’ve shared information

When it comes to your health information, you

• You can ask for a list (accounting) of the times we’ve
shared your health information for six years prior to Our Uses & Disclosures
have certain rights. This explains your rights and our the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those How do we typically use or share your
responsibilities to help you. health information? We typically use or
about treatment, payment, and health care
operations, and certain other disclosures (such as share your information in the following
Get a copy of your medical record
• You can ask to see or get an electronic or any you asked us to make). We’ll provide one ways:
paper copy of your medical record and other accounting a year for free but will charge a
health information we have about you. You will reasonable, cost-based fee if you ask for another Treat you
need to sign a record request form. Ask us how one within 12 months. • We can use your health information
to do this. and share it with other professionals
• We will provide a copy or a summary of your Choose someone to act for you
who are treating you. Example: A
health information, usually within 30 days of your • If you have given someone medical power of
attorney or if someone is your legal guardian, that doctor treating you for an injury asks
request. We may charge a reasonable, cost- another doctor about your overall
based fee. Receive information about your person can exercise your rights and make choices
about your health information. health condition.
diagnosis, condition, and treatment in terms you
can understand. • We will make sure the person has this authority and
can act for you before we take any action. Run our organization
Ask us to correct your medical record • We can use and share your health
• You can ask us to correct health information File a complaint if you feel your rights are violated information to run our practice,
about you that you think is incorrect or • You can complain if you feel we have violated your improve your care, and contact you
incomplete. Ask us how to do this. rights by contacting us using the information on the
when necessary. Example: We use
• We may say “no” to your request, but we’ll tell back page.
• You can file a complaint with the U.S. Department of health information about you to
you why in writing within 60 days. manage your treatment and service.
Health and Human Services Office for Civil Rights by
Request confidential communications sending a letter to 200 Independence Avenue, S.W.,
• You can ask us to contact you in a specific way Washington, D.C. 20201, calling 1-877-696-6775, or Bill for your services
(for example, home or office phone) or to send visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We can use and share your health
mail to a different address. • We will not retaliate against you for filing a complaint information to bill and get payment
• We will say “yes” to all reasonable requests. from health plans or other entities.
Example: We give information about
Ask us to limit what we use or share
• You can ask us not to use or share certain Our Responsibilities you to your health insurance plan so it
will pay for your services.
health information for treatment, payment, or
our operations. • We are required by law to maintain the privacy and
security of your protected health information. We are allowed or required to share your
• We are not required to agree to your request,
and we may say “no” if it would affect your information in other ways – usually in
care. • We will let you know promptly if a breach occurs that ways that contribute to the public good
may have compromised the privacy or security of (such as public health or research), or
• If you pay for a service or health care item out-
your information. fulfill other duties (such as complying with
of-pocket in full, you can ask us not to share
that information for the purpose of payment or the law and following government
our operations with your health insurer. • We must follow the duties and privacy practices
described in this notice and give you a copy of it.
requests).
• We will say “yes” unless a law requires us to
share that information. We have to meet many conditions in the
• We will not use or share your information other than as
described here unless you tell us we can in writing. If law before we can share your
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at
you tell us we can, you may change your mind at any information for these purposes. For more
time. Let us know in writing if you change your mind. information see:
any time, even if you have agreed to receive
the notice electronically. We will provide you www.hhs.gov/ocr/privacy/hipaa/underst
For more information see: anding/consumers/index.html.
with a paper copy promptly.
www.hhs.gov/ocr/privacy/hipaa/understanding/consum
ers/noticepp.html.