About Us: Privacy Statement
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW BELOW CAREFULLY.

Who We Are:
I. This Notice describes the privacy practices of Advance Potential Psychological Services (APPS) psychologists, social workers, therapists,
administrative/office personnel and other personnel. It applies to services furnished to you through Advance Potential Psychological Services. Our
Privacy Obligations: We are required by law to maintain the privacy of your mental health information ("Protected Health Information" or "PHI") 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 your
Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

II. Permissible Uses and Disclosures without Your Written Authorization:
In certain situations, which we will describe in Section IV below, we must obtain your written consent or authorization ("Your Authorization") in order
to use and/or disclose your PHI. However, unless the PHI is highly confidential information and the applicable law regulating such information
imposes special restrictions on us, we may use and disclose your PHI without Your Authorization for the following purposes:

A. Treatment, Payment and Health Care operations. We may use and disclose PHI, in order to treat you, obtain payment for services provided to
you and conduct our health care operations as detailed below. APPS policies and procedures require that we obtain your written
consent/authorization in order to disclose most PHI.
•Treatment. We use and disclose your PHI to provide treatment and other services to you-for example, to diagnose and treat your injury or
illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health
related benefits and services that may be of interest to you. We may also disclose PHI to the providers involved in your treatment. (APPS
policies and procedures require that we obtain your written consent/authorization in order to disclose most PHI)
•Payment. We may use and disclose your PHI to obtain payment from Medicare, Medicaid or another governmental program that
arranges or pays the cost of some or all of your health care, for services that we provide to you. We will obtain your authorization to
disclose PHI to your private health insurer i.e., HMO, PPO or other private payers.
•Health Care Operations. We may use and disclose your PHI for our health care operations, which include internal administration and
planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. We may disclose PHI to
our Patient Relations Coordinator in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.

B. Disclosure to Relatives Close Friends and Other Caregivers: We may use or disclose your PHI to a family member, other relative, a close
personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain
your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; (3) reasonably infer that you do not object
to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of
your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best
interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we
believe is directly relevant to the person's involvement with your health care or payment related to your health care. We may also disclosure your
PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

C. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health
authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to the Illinois
Department of Children and Family Services or other government authorities authorized by law to receive such reports; (3) to report information
about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed
to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your
employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

D. Victims of Abuse Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may
disclose your PHI to the Illinois Department of Children and Family Services, the Illinois Department of Human Services or other governmental
authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic
violence.

E. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with
responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

F. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a
legal order or other lawful process. Further, unless specifically authorized by a court order, we may not use or disclose PHI identifying you as a
recipient of substance abuse program services if the purpose is to initiate or substantiate any criminal charges against you or to conduct any
investigation of you.

G. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in
compliance with a court order or a grand jury or administrative subpoena.

H. We may disclose your PHI to a coroner or medical examiner as authorized by law.

I. Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or
safety.

J. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S.
military or the U.S. Department of State under certain circumstances.

K. Workers Compensation. We may disclose your PHI as authorized by, and to the extent necessary to comply with, state law relating to
workers' compensation or other similar programs.

L. As required by law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding
categories.

III. Uses and Disclosures Requiring Your Written Authorization.

For any purpose other than the ones described in Section II above, we may only use or disclose your PHI when you give us your authorization
on our authorization form.

A. Private Payers: We must obtain Your Authorization to disclose PHI to your health insurer and/or other private payer.

B. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and Illinois law impose special privacy protections for
"Highly Confidential Information", including Psychotherapy Notes and the subset of Protected Health Information that is related to: (1) treatment
of a mental illness; (2) alcohol and drug abuse treatment program services; (3) HIV/AIDS testing; (4) child abuse and neglect (5) sexual
assault; and (6) genetic testing. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by laws
regulating Highly Confidential Information, we must obtain Your Authorization.

IV. Your Rights Regarding Your Protected Health Information

A. For Further Information or Privacy Rights Complaints. If you desire further information about your privacy rights, are concerned that we have
violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact us.  You may also file written
complaints with the APPS CEO, Office for Civil Rights of the U.S. Department of Health and Human Services.  We will not retaliate against you if
you file a complaint with us or the Director.

B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and
health care operations, (2) to individuals (such as a family member, other relative(s), close personal friend(s) or any other person identified by
you, or involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your
location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a
requested restriction. If you wish to request additional restrictions, please obtain a request form from our website and submit for consideration.

C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to
receive your PHI by alternative means of communication or at alternative locations.

***D. Right to Revoke Your Authorization. You may revoke Your Authorization, except to the extent that we have taken action in reliance upon it, by
delivering a written revocation statement to the  APPS CEO. A form of Written Revocation is available upon request from CEO Glenn Sevier.

E. Right to Inspect and Copy Your Health Information. You may request access to your medical record 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, please obtain a record request form from Glenn Sevier, CEO.

F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record
file or billing records. If you desire to amend your records, please obtain an amendment request form from Glenn Sevier, CEO. We will comply
with your request unless amending would falsify the information or other special circumstances apply.

G. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us
during any period of time prior to the date of your request provided such period does not exceed six years.

H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such
notice electronically.

V. Effective Date and Duration of This Notice

A. 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 for 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 the APPS waiting area.
2007 W. Greenleaf, Chicago, IL 60645
PHONE 773-512-8813    |    FAX 773-743-7696
2016 Advance Potential Psychological Services