Notice of Privacy Practices


At Sertoma Centre, Inc., we respect client confidentiality and only release protected health information about you in accordance with Illinois and federal law. This notice describes our policies related to the use and disclosure of the records of your care generated by this agency and the rights that you have with regard to our use, receipt, and disclosure of your protected health information.

By law we are required to keep protected health information about you private. We are additionally required to give you this notice of our legal duties and privacy practices with respect to protected health information about you, and to notify you following a breach of unsecured protected health information. Moreover, we are required to follow the terms of the Notice of Privacy Practices that is currently in effect.

Privacy Contact/Officer. If you have any questions about this policy or your rights, contact:

Director of Human Resources

Sertoma Centre, Inc.
4343 W. 123rd Street
Alsip, IL 60803
Phone: (708) 371-9700, x 212


In order to effectively provide you care, there are times when we will need to share your medical information with others beyond our agency,

Information That May Be Disclosed Without Your Consent

The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed with or without your written consent:

Notice of Privacy Practices

Treatment: We may use or disclose protected health information about you to provide, coordinate, or manage your care or any related services, including sharing information within our organization and with others outside our agency who we are consulting with or referring you to, or with whom you are seeking medical treatment.

Example: Sharing information with other licensed therapists consulting on the best course for your treatment.

Payment: Disclosure of your protected health information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment for billing purposes, as applicable.

Example: Sharing information with the Department of Mental Health (DMH) as needed to secure payment from DMH for treatment being provided to you.

Health Care Operations: We may use protected health information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, or training staff.

Example: We call you to confirm your upcoming appointment and the services you will be receiving.

Emergencies: Sufficient information may be shared to address the immediate emergency you are facing.

As Required by Law: This would include situations where we have a subpoena, court order, or are required to report your protected health information for safety and/or public health reasons, such as in situations regarding communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.

Coroners, Funeral Directors, and Organ Donation: We may disclose information to a coroner or medical examiner and funeral directors for the purposes of carrying out their duties. When organs are donated, sufficient information will be provided to the program as necessary to facilitate the organ or tissue donation in certain circumstances.

General Requirements: We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. There also might be a need to share your protected health information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested, with the Department of Health and Human Services to determine our compliance with federal laws related to healthcare.

Criminal Activity or Danger to Others: If a crime is committed on our premises or against our personnel, we may share your protected health information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.

Information That May Be Disclosed Only With Your Consent

The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed only with your written consent or authorization:

• Most uses and disclosures of psychotherapy notes.
• Uses and disclosures of protected health information for marketing purposes, including subsidized treatment communications.
• Disclosures that constitute a sale of protected health information.
• Other uses or disclosures of your protected health information not described in this Notice of Privacy Practices.

You may revoke an authorization at any time, provided that the revocation is in writing, subject to some restrictions.


Fundraising: As a not-for-profit provider of healthcare services, we need assistance in raising money to carry out our mission. For example, we may contact you to seek a donation for a charitable event benefiting Sertoma Centre, Inc. At any time, you have the right to opt out of receiving such communications by … [on every piece of fundraising communication, you must provide the recipient with a way he or she may opt out of receiving future communications; e.g., to opt out of future fundraising communications, respond to this email with ‘unsubscribe’ in the subject line” or “contact

at [phone number] or [email address] if you do not wish to receive future fundraising communications.”

Treatment Information: We may contact you to provide appointment reminders or information regarding treatment alternatives or other health-related benefits and services that may be of interest to you. For example, we may call you to confirm your upcoming appointment and the services you will be receiving during the appointment to treat your medical condition.

You have the following rights under Illinois and federal law:

Inspect/Obtain a Copy of Records: You are entitled to request access to inspect or to obtain a copy of the medical records our agency has generated about you. [Optional] Your request must be in writing and directed to the Privacy Officer. We will respond to any requests within 30 days after receipt of the request. We may charge you a reasonable fee for copying and mailing your records.

Release of Records: You may consent in writing to the release of your medical records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Restriction on Records: You may ask us not to use or disclose part of the protected health information we have on you. This request must be in writing. In most cases, the agency is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information. If your have paid for services out-of-pocket, in full, and you request that Sertoma Centre, Inc. not disclose the protected health information to a health plan, we must accommodate that request unless otherwise required to disclose the information by law. The request should be submitted to the Privacy Officer.

Contacting You: You may request that we send information to another address or by alternative means. We will honor such a request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. We also will be glad to provide you information by e-mail if you request it. If you wish for us to communicate by e-mail, you are also entitled to a paper copy of this Privacy Notice.

Amending Record: If you believe that your protected health information in your medical record is incorrect or incomplete, you may request we amend it. To do this, contact the Privacy Officer in writing and ask for the Request to Amend Protected Health Information form. You must complete the Request to Amend Protected Health Information form and return it to the Privacy Officer. The agency will respond to your request within 60 days of receipt of the Request to Amend Protected Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment, you have the right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.

Accounting for Disclosures: You may request an accounting of any disclosures we have made related to your protected health information during the six (6) years prior to your request. The following disclosures may be excepted from this accounting: (1) Information we used for treatment, payment, or healthcare operations purposes; (2) Information that we shared with you or your family; (3) Information that you gave us specific consent to release; (4) For Sertoma Centre, Inc.’s directory or to the persons involved in your care or for other notification purposes; (5) For national security or intelligence purposes; (6) To correctional institutions or law enforcement officials; (7) Information we were required to release; and, (8) As part of a limited data set. Your first accounting will be provided free of charge. Sertoma Centre, Inc. may impose a reasonable fee for any subsequent request for accounting received within the same twelve (12) month period. To receive information, please submit your request for accounting in writing to the Privacy Officer.
Confidential Communications: You have the right to request and receive, when reasonable, confidential communications pertaining to your protected health information. [Optional] Your request must be in writing and directed to the Privacy Officer.

Questions and Complaints: If you have any questions, or wish a copy of this Policy or have any complaints, you may contact the Privacy Officer in writing at our office for further information. You may also complain to the Secretary of Health and Human Services if you believe our agency has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Policy: The agency reserves the right to change this Notice of Privacy Practices and all policies and requirements set forth herein based on the needs of the agency and changes in state and federal law. Changes will apply to medical information we already hold, as well as new information after the change occurs. Upon revision of the practices described in this Notice of Privacy Practices, we will post the new notice in our office and website, and provide you with a revised copy upon your next visit [or send electronically, via US mail to last available address].

Revised: 3/3/14