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This notice describes how medical and clinical information about you may be
used and disclosed and how you can get access to this information. Please
review it carefully.

I. Who We Are

This notice describes the privacy practices of SJ Associates and Lorraine K. Bockman, LCSW, CACIII.

II. Our Privacy and Confidentiality Obligations

We are required by law to maintain the privacy and confidentiality of information about your health, health care, and payment for services related to your health (referred to in this notice as "protected health information" or "information"); and to provide you with this notice of our legal duties and privacy practices with respect to your protected health information. When we use or disclose this information, we are required to abide by the terms of this policy.

The Federal Confidentiality Law, 42 U.S.C & 290dd-2, 42 C.F.R. Part 2 and the Federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 U.S.C. & 1320d et seq., 45 C.F.R. Parts 160 & 164 protect your health information if you are applying for or receiving services (including diagnosis, referral or treatment) for drug or alcohol abuse. If you are applying for or receiving services for drug or alcohol abuse, the provider is prohibited from disclosing any information, including involvement and participation in assessment and treatment services, payment information, and assessment and treatment results, to a person or agency without your express permission in writing. There are several exceptions to this regulation, which are listed in this notice.

1. We may use or disclose your protected health information when you give your authorization to do so in writing on a Release of Information form that specifically meets the requirements of the laws and regulations that apply.
   
   
2. You may revoke your authorization except to the extent that we have already taken action upon the authorization. If you wish to revoke your authorization, you may do so verbally or in a written statement.
   
   
3. Please be aware that a court with appropriate jurisdiction or other authorized third party may request that you to sign a Release of Information. Failure to do so may result in consequences for you that are beyond our control.
   

There are circumstances that we are required to use and disclose your protected health information even though you have not provided your authorization in writing. These circumstances are listed below.

1. Health Care Operations: We may use or disclose your protected health information for the purposes of health care operations within our agency. However, the information used may not identify, directly or indirectly, or otherwise disclose the identities of any individual in any final report. Health care operations may include internal administration, planning, and activities that improve the quality and effectiveness of client care. For example, we may use information about your care to evaluate the quality and competence of our clinical staff or to resolve any complaints or issues that arise regarding your care. We may disclose information to qualified personnel for outcome evaluation, management audits, financial audits, or program evaluation. We may also disclose your protected health information to an agent or agency which provides services to our organization under a Qualified Service Organization Agreement (QSOA) and/or a Business Associate Agreement (BAA), in which they agree to abide by the applicable federal laws and related regulations (42 CFR Part 2 and HIPAA). Health Care Operations may also include the use of your protected health information to contact you regarding future appointments or to provide you with information regarding additional programs offered by our organization. This list of examples is for illustration only and is not an exclusive list of all of the potential uses and disclosures that may be made for health care operations.



2. Medical Emergencies: We may disclose your protected health information to medical personnel to the extent necessary to meet a bona fide medical emergency (as defined by 42 CFR Part 2).



3. Judicial and Administrative Proceedings: We may disclose your protected health information in response to a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records.



4. Commission of a Crime on Premises or against Program Personnel: We may disclose your protected health information to the police or other law enforcement officials if you commit a crime on the premises or against program personnel or threaten to commit such a crime.



5. Abuse: We may disclose your protected health information for the purpose of reporting child or elder abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports.



6. Duty to Warn: We may disclose your protected health information for the purpose of reporting a specific threat of serious physical harm to another specific person or the public. Information may be provided to the specific person, to the police, to other law enforcement agencies, or to government authorities as appropriate.
   
   
7. Audit and Evaluation Activities: We may disclose protected health information to those who perform audit or evaluation activities for certain health oversight agencies. Such agencies might include the Colorado Alcohol and Drug Abuse Division (ADAD) or the Department of Regulatory Agencies (DORA), independent accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or federal agencies monitoring client care such as the Department of Transportation.
   
   
8. Department of Transportation Referrals: If you are applying for or receiving services (including diagnosis, referral or treatment) for drug or alcohol abuse under the Department of Transportation Regulations 49 CFR Part 40 regarding substance abuse, a written Release of Information is not required in certain cases. The evaluator may confer with your employer, with the Medical Review Officer (MRO) and the treatment provider without your written authorization.
   

1. Right to Receive Confidential Communications: We will communicate with you through the phone number, street address, or email address that you provide. You may request, and we will accommodate, any reasonable, written request for you to receive your protected health information by alternative means of communication or at alternative locations.
   
   
2. Right to Request Additional Restrictions: You may request restrictions on our use and disclosure of protected health information for treatment, payment and health care operations. We will consider all requests for additional restrictions carefully however; we are not required to comply with requested restrictions. If you wish to request additional restrictions and you are currently receiving services, please contact your therapist. Once you are no longer receiving services, contact our organization in writing. We will send you a written response.
   
   
3. Right to Inspect and Copy Your Health Information: You may request access to your clinical file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records and you are currently receiving services, please ask your therapist for the records. Once you are no longer receiving services, contact our organization in writing. If you request copies, there will be a charge for each page copied and you will be told the cost prior to the copies being made.
   
   
4. Right to Amend Your Records: You have the right to request that we amend protected health information maintained in your clinical file or billing records. Our organization may approve or deny your request dependent on the circumstances. If your request to amend your records is denied, we will notify you of this denial in writing. If your requested amendment to your records is accepted, a copy of your amendment request will become a permanent part of your record. When we "amend", a record, we may add information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement of disagreement placed in your medical records. If you desire to amend your records and you are currently receiving services, contact your therapist. Once you are no longer receiving services, contact our organization in writing.
   
   
5. Right to Receive an Accounting of Disclosures: Upon request, you may obtain a list of instances that we have disclosed your protected health information without your written authorization; in those instances related to your treatment and payment for services; or in the course of our health care operations. The list will apply only to covered disclosures prior to the date of your request. If you request an accounting more than once during a twelve (12) month period, there will be a charge. You will be told the cost prior to the request being filled.
   
   
6. Right to Receive a Paper Copy of This Notice: Upon request, you may obtain a paper copy of this notice.

VI. Additional Information and Complaints.

If you desire further information about your privacy and confidentiality rights; if you are concerned that we have violated these rights; or if you disagree with a decision that we have made about access to your protected health information; you may contact the Privacy Office at 303-946-2358. You may also file a written complaint with the Secretary of the United States Department of Health and Human Services. Upon request, we will provide you with the correct address. We will not retaliate against you if you file a complaint. Violation of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney in the local district.

1. Effective Date: This notice is effective on June 1, 2007.

2. Right to Change Terms of This Notice: We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective to all protected health information that we maintain, including any information created or received prior to issuing the new notice. If we change this notice, we will post the new notice in public access areas at our service sites and on our Internet site. You may also obtain any new notice by contacting the Privacy Office.
   
   
3. Privacy Office: You may contact the Privacy Office at 303-946-2358.

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