By law The Family Center (TFC) is required to insure that your PHI is kept private.  The PHI is information created or noted by the staff at TFC that can be used to identify you. It contains data about your past, present or future health or condition, the health care services we provide for you, or the payment for such health care. The Family Center is required to provide you with this Notice about The Family Center’s (TFC) privacy procedures.  This Notice explains when, why and how TFC would use and/or disclose your PHI. Use of PHI means when TFC shares, apply, utilize, examine or analyze information within the center, PHI is disclosed when TFC releases, transfers, gives or otherwise reveals it to a third party outside the center. With some exceptions, TFC may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, TFC staff is always legally required to follow the privacy practices described in this Notice.


Please note that TFC reserves the right to change the terms of this Notice and TFC policy at any time. Any changes will apply to PHI already on file with the Privacy Officer. Before any important changes are made TFC will change this Notice and post a new copy of it in the Reception area immediately. You may also request a copy of this Notice from TFC staff or you can view a copy of at TFC.



The Family Center will use and disclose your PHI for different reasons. Some of the uses or disclosures will require your prior written authorization; other, however, will not. Below you will find the different categories of TFC uses and disclosures, with some examples.


A. Uses and Disclosures Related to Treatment, Payment or Health Care Operations (TPO) Do Not Require Your Prior Written Consent. TFC may use and disclose your PHI without your consent for the following reasons:

1. For treatment, TFC may disclose your PHI to physicians, psychiatrists, psychologists and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Examples: If a psychiatrist is treating you, TFC therapist may disclose your PHI to her/him in order to coordinate your care.

2. For health care operations. TFC may disclose your PHI to facilitate the efficient and correct operation of TFC organization. Examples: Quality control- TFC might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. TFC may also provide your PHI to TFC’s attorneys, accountants, consultants and others to make sure that TFC is in compliance with applicable laws.

3. To obtain payment for treatment. TFC may use and disclose your PHI to bill and collect payment for the treatment and services provided to you. Example: TFC might send your PHI to your insurance company or health plan in order to get payment for the health care services provided to you. TFC could also provide your PHI to business associates, such as billing companies, claim processing companies and others that process health care claims for TFC.

4. Other disclosures. Examples: Your consent isn’t required if you need emergency treatment provided that TFC staff attempt to get your consent after treatment is rendered. In the event that TFC staff try to get your consent, but you are unable to communicate (for example, if you are unconscious or in severe pain), but TFC staff think that you would consent to such treatment if you could, TFC staff may disclose your PHI.


B. Certain Other Uses and Disclosure Do Not Require Your Consent. TFC may use and/or disclose your PHI without your consent or authorization for the following reasons:

When disclosure is required by federal, state or local law; judicial, board or administrative proceedings; or law enforcement.


Example: TFC may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.If disclosure is compelled by a party to a proceeding before a court or an administrative agency pursuant to its lawful authority. If disclosure is required by a search warrant lawfully issued by a governmental law enforcement agency.If disclosure is compelled by the client or the client’s representative pursuant to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.To avoid harm. TFC may provide PHI to law enforcement personnel or persons able to prevent or lessen a serious threat to the health and safety of a person or the public.If disclosure is compelled or permitted by the fact that you are in such mental or emotional conditions as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.If disclosure is mandated by the Wisconsin Child Abuse and Neglect Reporting law.


For example: If TFC staff have a reasonable suspicion of child abuse or neglect. If disclosure is mandated by the Wisconsin Elder/Dependent Adult Abuse Reporting law. For example, if TFC staff have a reasonable suspicion of elder abuse or dependent adult abuse.If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.For public health activities.


Examples: In the event of your death, if a disclosure is permitted or compelled, TFC staff may need to give the county coroner information about you.For health oversight activities. Example: TFC staff may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider. Also when compelled by U.S. Secretary of Health and Human Services to investigate or assess TFC’s compliance with HIPAA regulations.For specific government functions.


Example: TFC may disclose PHI of military personnel and veterans under certain circumstances. Also, TFC may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.For research purpose. In certain circumstances, TFC may provide PHI in order to conduct medical research.For Workers’ Compensation purposes. To comply with Worker’s Compensation laws.Appointment reminders and health related benefits or services. Examples: TFC may use PHI to provide appointment reminders. TFC may use PHI to give you information about alternative treatment options or other health care services or benefits TFC offer. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g. a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law and is otherwise specifically required by law.


C. Certain Uses and Disclosures Require You to Have the Opportunity to Object

to Disclosure to family, friends and others. TFC staff may provide your PHI to a family member, friend or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.


D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB and IIIC above, TFC staff will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that TFC has not taken any action on the original authorization) of your PHI.



These are your rights:


A. The Right to See and Get a Copy of your PHI. In general, you have the right to see your PHI that is in TFC’s possession or get copies of it; however, you must request it in writing. If TFC do not have your PHI, but TFC knows who does, TFC will advise you how you can get it. You will receive a response from TFC’s Director within 30 days of receiving your written request. Under certain circumstances, TFC Director may feel s/he must deny your request, if so s/he will give you, in writing the reasons for the denial. TFC Director will also explain your right to have your denial reviewed. If you ask for copies of your PHI, TFC will charge you not more than $.45 per page. TFC Director may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.


B. The Right to Request Limits on Uses and Disclosure of Your PHI. You have the right to ask that TFC limit how to use and disclosure your PHI. While TFC Director will consider your request, s/he is not legally bound to agree. If TFC Director doesn’t agree to your request, s/he will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that TFC staff is legally required or permitted to make.


C. The Right to Choose How TFC Sends Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending it to your work address rather than your home address) or by an alternative method (for example: via fax instead of by regular mail). TFC is obliged to agree to your request providing that TFC can give you the PHI, in the format you requested, without undue inconvenience.


D. The Right to Get a List of the Disclosures TFC has Made. You are entitled to a list of disclosures. The list will not include uses or disclosures to which you have already consented, i.e. those for treatment, payment or health care operations (TPO), sent directly to you or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel or disclosures made before April 15, 2003, disclosure records will be held for seven years.


TFC will respond to your request for an accounting of disclosure within 60 days of receiving your request. The list TFC will give you will include disclosures made in the previous six years unless you indicate a shorter period. The list will include the date of the disclosure, to who PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. TFC will provide the list to you at no cost, unless you make more than one request in the same year, in which case TFC will charge you a reasonable fee for each additional request.


E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that TFC staff correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days upon receipt of your request. TFC Director may deny your request, in writing, if s/he finds that: the PHI is

(a) correct and complete, (b) forbidden to be disclosed, (c) not part of TFC’s records, or (d) written by someone other than TFC staff. TFC Director’s denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and TFC denial be attached to any future disclosures of your PHI. If TFC Director approves your request, s/he will make the change(s) to PHI. In addition, TFC Director will tell you that the changes have been made and s/he will inform all others who need to know about the change(s) to your PHI.


F. The Right to Get This Notice by Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.


V. HOW FILE A COMPLAINT ABOUT THE FAMILY CENTER’S PRIVACY PRACTICES. If, in your opinion, TFC has violated your privacy rights, or if you object to a decision TFC Director made about access to your PHI, you are entitled to file a complaint with Betty Rygiewicz, RN, MS, LMFT, the Director and Privacy Officer of The Family Center, 8025 Excelsior Drive, Madison, WI 53717-2902, and Phone: 608-663-6154. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. IF YOU FILE A COMPLAINT ABOUT TFC’S PRIVACY PRACTICES, TFC STAFF WILL TAKE NO RETALIATORY ACTION AGAINST YOU. IT WILL NOT CHANGE THE CARE TFC PROVIDES TO YOU IN ANY WAY.