Notice of Privacy Practices




(45 CFR §164.520(a))


Effective Date: 6/1/2007







Buck Black Therapy, LLC staff understands that your personal health information is protected.  We are committed to protecting your personal health information and will create a record of the care and services you receive at Buck Black.  This record is needed to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by Buck Black Therapy, LLC.


This notice will tell you about the ways in which we may use and disclose medical information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of your PHI.




This notice describes our practices and that of:


1.     All employees, professional staff and other personnel including volunteers of Buck Black Therapy, LLC.


2.     All these entities, sites and locations follow the terms of this notice.  In addition, these entities, sites and locations may share PHI with each other for treatment, payment or Buck Black Therapy, LLC operations purposes described in this notice.


We are required by law to:


·         make sure that PHI that identifies you is kept private;


·         give you this notice of our legal duties and privacy practices with respect to PHI about you; and


·         follow the terms of the notice that is currently in effect.


*Protected Health Information (PHI):  Any information, whether oral or recorded in any form or manner that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearing house; and relates to the past, present or future physical or mental health or condition of a client; the provision of health care to a client; or past, present, or future payment for the provision of health care to a client.






Ø      As Required By Law.  We will disclose PHI about you when required to do so by federal, state or local law.


Ø      To Avert a Serious Threat to Health or Safety.  We will use and PHI about you when we have a “Duty to Report” under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat.


Ø      Public Health Risks.  We will disclose PHI about you for public health reporting required by federal or state law.  These activities generally include the following:


·         to prevent or control disease, injury or disability;


·         to report child abuse or neglect;


·         to report reactions to medications or problems with products;


·         to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;


·         to notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.


Ø      Health Oversight Activities.  We will disclose PHI as required by law to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.


Ø      Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we will disclose PHI about you when properly ordered to do so by a court.


Ø      Law Enforcement.  We will release PHI if asked to do so by a law enforcement official, and if permitted by law:


·         In response to a court order;


·         If required by state or federal law;


·         To identify or locate a suspect, fugitive, material witness, or missing person;


·         About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;


·         About a death we believe may be the result of criminal conduct;


·         About criminal conduct at a Buck Black Therapy, LLC facility; and


·         In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.


Ø      Protective Services  We will disclose PHI about you to authorized federal officials so they may provide protection to individuals or conduct special investigations.




Ø      We may use PHI about you to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other Buck Black Therapy, LLC personnel who are involved in taking care of you; or, to people outside Buck Black Therapy, LLC, such as other health care providers involved in providing health care treatment for you and to people who may be involved in your personal health care, such as family members, clergy or others we use to provide services that are part of your care.


Ø      We may use and disclose PHI about you so that the treatment and services you receive at Buck Black Therapy, LLC may be billed to, and payment may be collected from, you, an insurance company or a third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.


Ø      We may use and disclose PHI about you for Buck Black Therapy, LLC operations or to your other health care providers or health plans.  These uses and disclosures are necessary to run Buck Black Therapy, LLC and make sure that all of our Clients receive quality care.


Ø      We may use and disclose PHI to contact you as a reminder that you have an appointment for treatment at Buck Black Therapy, LLC.


Ø      We may release certain limited information about you to a friend or family member who is involved in your health care.  We may also give information to someone who helps pay for your care.  We may also tell your family or friends your condition.




You have the following rights regarding medical information we maintain about you:


Ø      You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes.


We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to PHI, under some circumstances you may request that the denial be reviewed.  Another licensed health care professional chosen by Buck Black Therapy, LLC will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.


Ø      Right to Amend.  If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for Buck Black Therapy, LLC.


We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the medical information kept by or for Buck Black Therapy, LLC;


·               Is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.


Ø      Right to an Accounting of Disclosures.  You have the right to request a list of the disclosures we made of medical information about you.  Your request must state a time period that may not be longer than six years and may not include dates before February 26, 2003.  Your request should indicate in what form you want the list (for example, on paper, electronically).  The first list you request within a 12 month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.


Ø      Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a specific treatment session you had.


We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.




Right to Request Confidential Communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.   Your request must specify how or where you wish to be contacted.


Ø      Right to a Paper Copy of This Notice.  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time. A paper copy of this notice may be obtained 100 Saw Mill Rd. Ste. 3102 Lafayette, IN 47905 in person or by writing to the same address c/o the Customer Service Representative.




Ø      We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in each of our facilities.  The notice will contain on the first page, in the top right-hand corner, the effective date.  In addition, each time you register at or are admitted to Buck Black Therapy, LLC for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.




If you believe your privacy rights have been violated, you may file a concern with Buck Black Therapy, LLC or with the Secretary of the Department of Health and Human Services.


You will not be penalized for filing a concern.




Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.   You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.


Requests to inspect and copy your PHI, to amend your PHI, for a list of your PHI disclosures, to request restrictions on disclosures of your PHI, to request confidential communications about your PHI, or to file a concern if you believe your privacy has been violated, you must do so in writing to Buck Black Therapy, LLC’s Medical Record Department at 100 Saw Mill Rd. Ste. 3102 Lafayette, IN 47905.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.