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 IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US
Our Legal Duty
Thomas Gill & Associates, PC (TGA)
TGA is required by federal and state law to maintain the privacy of your medical information. TGA is also required to provide you with this notice about our privacy practices, our legal duties, and your rights concerning your medical information.
This notice takes effect Sept. 1, 2023, and will remain in effect until it is revised and/or updated.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted under law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes.
When changes are made to the notice, the updated document will be available to you upon request.
TGA provides its Notice of Privacy Practices to every client with whom it has a direct coaching relationship. The Notice is provided no later than the date of first consultation to clients after April 13, 2003. When a direct treatment client receives the Notice, TGA asks clients to sign its "Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices" form. You may request a copy of this notice at any time.
Using and Disclosing Your Medical Information
TGA reasonably ensures that the protected health information (PHI) it requests, uses, and discloses for any purpose is the minimum amount of PHI necessary for that purpose.
TGA makes reasonable efforts to ensure that PHI is only used by and disclosed to individuals who have a right to protected health information. Toward that end, TGA makes reasonable efforts to verify the identity of those using or receiving PHI.
We must disclose your medical information to you, as described in the Individual Rights section of this notice. We may disclose your medical information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.
We use and disclose medical information about you for treatment, payment, and health care operations. For example:
Coaching could include consulting with or referring your case to another health care provider such as a physician, psychologist, therapist, clinic, or hospital. The type of health information that could be used or disclosed includes medical history, diagnoses, medications, or care plans pertinent to your care.
Payment means we may use and disclose your medical information to obtain payment for services provided to you.
Uses or Disclosures We May Make Without Your Authorization
Thomas Gill & Associates uses and discloses protected health information to appropriate individuals as required by law.
The practice discloses protected health information regarding victims of abuse, neglect, or domestic violence. The practice discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adult abuse.
The practice informs the individual of the reporting unless the practice, in the exercise of professional judgment, believes informing a personal representative, and the practice believes the personal representative is responsible for the abuse, neglect, or other injury and that information such person would not be in the best interests of the individual as determined by the professional judgment of the practice.
- We may also use and disclose medical information in the following manner:
- We may contact you by phone or by mail to provide information about help alternatives or other health-related services that may be of interest to you.
- We may disclose your medical information in response to a court or administrative order or other lawful process under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may disclose your medical information to law enforcement officials.
- We may disclose your medical information when we are required to do so by federal, state, or other applicable law. We may disclose your medical information when authorized by workers' compensation or similar laws.
- We may disclose protected health information for military and veterans activities, national security and intelligence activities, and other activities as required by law.
If you are an unemancipated minor under Illinois law, then Thomas Gill & Associates will not disclose, without your authorization, information related to your care regarding treatment abuse of drugs or alcohol or emotional disturbance to a parent, legal guardian, person standing in loco parentis or a legal custodian who has the legal authority to provide permission for your medical or psychiatric care.
You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. You must make your request in writing. We will accommodate your request if it is reasonable, specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.
You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we do not create the information you want amended or for certain other reasons.
Full payment is due at the time of service. Pay your provider directly upon completion of your session. (For your convenience, you may provide us with a credit card number to keep on file. Session fees will be automatically posted the next day.
Every client receives a superbill. If you are submitting to an insurance company, you can send in the superbill with a copy of your insurance card for reimbursement.
On the superbill, providers often note your next appointment. Please pay careful attention to this detail, as appointments not canceled within 24 hours of appointment time are charged to the client at the session price.
CARE COORDINATION SERVICES
Depending on your specific needs, your coach may spend significant time outside of office visits managing your care. These duties may include reviewing school, hospital, or lab records; talking with outside therapists or doctors; completing forms for disability, schools, and health or prescription insurance authorizations; generating letters and filling out reports; filling prescriptions or answering questions about medications, communicating with extended family, hospitals or agencies involved in your care, etc. The needs of children, teens, and the elderly are especially time-intensive.
Office Policy and Informed Consent
State laws require that most issues discussed during the course of coaching with a coach, are confidential. These laws permit you to waive the privilege of confidentiality by signing a "Release of Information Form." However, the release of confidential materials is required in situations of suspected child abuse or potential harm to oneself or others and in instances where the court may subpoena records. During the course of your coaching, you may request that some information be discussed with another person (i.e., your physician, spouse/partner, children, parents, etc.) If you desire that information be communicated about you to someone else, please ask for a "Release of Information Form." If we feel that it will be useful to you during the course of your coaching to discuss your progress or situation with another person (i.e., your physician), your coach will request your written permission to do so and will not release that information without such written permission.
Coaching sessions will typically be on a weekly or bi-weekly basis. Additional appointment times can be arranged with your coach. A coaching "hour" is 45 minutes in duration and is referred to as a "clinical hour."
Cancellations and Missed Appointments:
It is requested that you provide advance notice of cancellation at least 24 hours before a scheduled appointment. If a cancellation has not been made prior to this time, the session is a loss for someone else wishing to use that coaching time. A scheduled appointment means that it will be held only for you and, therefore, cannot be used by another person. Late cancellations or appointments not canceled will be billed as a "failed appointment." Failed appointments will be billed at your regular session feel. Most insurance companies do not cover failed appointments, resulting in the clients themselves being solely responsible for any such charges. If you are late, the session will still end at the scheduled end time.
Fees are not charged for phone calls to coaches regarding appointments and similar matters. As well, fees are not charged for phone calls requiring just a few minutes. However, a pro-rated charge will be made for coaching consultations conducted over the phone that require more than 5 minutes. This would be billed at the same rate as face-to-face sessions. Phone calls may be made from our offices for emergencies.
You will be billed for all time spent with you or on your behalf, including the coaches time spent preparing reports, reading letters or other documents, consultations, travel time for "out of office" services, and telephone calls. A list of all coaching/consultation fees is available by request. Payment is requested at the time of each session, either by cash, check, or charge card. Each clients remains responsible for any outstanding fee,
In the event that a check given for payment of your account is returned by your bank, a charge of $50.00 will be added to your account.
Ethical and Professional Standards:
As professional coaches, we work diligently to uphold the most responsible, ethical, and professional standards possible, and we are accountable to you. If you have any questions or concerns about your course of contact with us, please feel free to discuss these issues with us. In signing this contract, you agree that should you have any dissatisfaction or concern about your treatment, you will do your best to indicate your concerns to us so we can attempt to address them to your satisfaction. If you are unhappy with your services here and need help finding additional or alternative resources, we will assist you in locating a more suitable referral source.
Coaching May be Upsetting:
You need to be aware that engaging in coaching may involve experiencing uncomfortable past traumatic events and difficult, intense emotions such as depression, anger, grief, confusion, or anxiety. It may also result in changes in your life that could be difficult to face. Your coach will discuss these situations with you if they come up in the course of coaching.