Chicago Mind and Body




Effective date: 2/08/2017

Chicago Mind and Body, PLLC and its employees have been and will always be totally committed to maintaining client confidentiality. We will only release healthcare information about you in accordance with federal and state laws and within the bounds of the ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information. Your counselor, Sarah Farris, LCPC, documents and stores your information using a secure electronic health record software.

Uses and disclosures of your health information for the purposes of providing services:  Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.  State and federal laws allow us to use and disclose your health information for these purposes.

TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services, which could include disclosure to consultants and potential referral sources.

PAYMENT We may use or disclose information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims, and as needed for billing or collection purposes.  We may bill the person in your family who pays for your insurance if insurance is used for services, and such bills would contain information about you.


We may need to use information about you to review our internal procedures and business activities. Information may be used for certification, compliance and licensing activities.

Other uses or disclosures of your information which do not require your consent: There are some instances where we may be required to use and disclose information without your consent.  For example::

  1. If you or your child/children report to us any physical or sexual abuse, then Illinois State Law requires us to report this to the Department of Children and Family Services;
  2. If you provide information that indicates to us that you are in danger of harming yourself or others, then Illinois State Law requires us to report this to the Department of Human Services.  
  3. Information to remind you of /or to reschedule appointments or treatment alternatives.
  4. Information shared with law enforcement if a crime is committed on our premises or against our staff, or
  5. As may otherwise be required by law, such as in response to a subpoena or court order.

You have a right to restrict any disclosure of personal health information where you have paid for services out-of-pocket and in full, without relying on any insurance or other third party payor.

All disclosures of clinical records, psychotherapy notes and other information related to your counseling services at CMB that are not covered by the categories listed above require a separate signed release of information. You have a right to and will receive notification of any breach of your unsecured personal health information.


Right to request how we contact you
It is our normal practice to communicate with you about health matters such as appointment reminders etc., at your email, home address, or the daytime phone number you gave us when you scheduled your appointment. Occasionally we may leave messages on your voicemail. You have the right to request that our office communicate with you in a different way.  

Right to release your medical records
You may consent in writing to release of your records to others. You have the right to revoke any such authorization, in writing, at any time. However, a revocation is not valid to the extent that we have already acted in reliance on any such authorization.

Right to inspect and copy your medical and billing records.
You have the right to inspect and obtain a copy of your information contained in our medical records. Under limited circumstances, we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your medical records.
If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or in some cases within 90 days. Under certain circumstances, we may deny your request to add or amend information.  If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager.  You must submit your request in writing and provide an explanation concerning the reason for your request.

Right to an accounting of disclosures.
You may request an accounting of disclosures, if any, we have made to others of your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. Any accounting of disclosures will also exclude information we were required to release. To receive information regarding disclosures, please submit your request in writing to the CMB office manager.  We will notify you of the cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our office manager. However, we are not required to agree to such a request.

Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns.  If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.

Right to receive changes in policy.
You have the right to receive any future Chicago Mind and Body policy changes, including changes resulting from changes in state and federal laws.