PRIVACY NOTICE 

This notice describes how medical information about you may be used and disclosed and how you can  access this information. Please review it carefully. 

The  Health  Insurance  Portability  and  Accountability  Act  of  1996  (HIPAA)  requires  that  health  care  practitioners create a notice of privacy practices for you to read. This notice tells you how Unlocking The  Spectrum will  protect  your  medical  information,  how  we  may  use  or  disclose  this  information,  and  describes  your  rights.  If  you  have  any  questions,  please  contact  the  Company Director  at  (812)-606- 4413.

Understanding Your Health Information 

The  privacy  rules  generally  allow  the  use  and  disclosure  of  your health  information  without  your  permission  (known as an authorization)  for purposes of health care Treatment and Payment activities.  Here are some examples of what that might entail: 

• Treatment includes providing, coordinating or managing health care and treatment. Treatment  can also include coordination or management of care between the “Company” and a third party  who may contribute to your care, and consultation and referrals between providers.  
• Payment  includes  activities  by  the  Company to  make  coverage  determinations  and  provide  reimbursement  for health care with third-party payers  (health insurance companies).  This can  include eligibility  determinations,  reviewing  services  for medical  necessity  or  appropriateness,  claims management and billing. 

Your Health Information Rights 

You have the following rights related to your medical records: 

• Obtain a copy of this notice 
• Authorization  to  use  your  health  information.  Before  Unlocking  The  Spectrum can  use  or  disclose  your  health  information,  other  than  as  described  below,  I  will  obtain  your  written  authorization, which you may revoke at any time to stop future use or disclosure. 
• Access  to  your  health  information.  You  may  request  a  copy  of  your  medical  record  from  Unlocking The Spectrum at any time. 
• Change your health information. If you believe  the information in your  record is inaccurate or  incomplete, you may request that Unlocking The Spectrum correct or add information. • Request  confidential  communications. You may  request  that when we  communicate with  you  about your  health information, we  do  so in a  specific way  (e.g.  certain mail address  or  phone  number). We will make every reasonable effort to agree to your request. 
• Accounting of disclosures. You may request a list of disclosures of your health information that  Unlocking The Spectrum has made for reasons other than treatment or payment.

Unlocking The Spectrum 

Phone: (317) 334-7331  ·  Fax: (317) 334-7336 

Rev. 1.2017 

Our Responsibilities 

• We are required by law to protect the privacy of your health information, to provide this notice  about our privacy practices and to abide by the terms of this notice. 
• We  reserve  the  right  to change our policies and procedures  for protecting health information.  When we make significant changes on how we use or disclose your health , we will also change  this notice. 
• Except for purposes related to your treatment, to collect payment for our services, to perform  necessary business functions or when otherwise permitted or required by law. We will not use  or  disclose  your  health  information  without  your  authorization.  You  have  the  right  to  revoke  your authorization at any time. 

When can We Legally Disclose Your Health Information Without Your Specific Consent? • In order to facilitate your medical treatment. 

• In order to collect payment for health care services that we provide. For example, in order to get  paid our billing agency will send a bill to you or your insurance company. Some of the employees  of this company have access to a small portion of your health information in order to do their  job.  The  information  on  the  bill  may  include  information  that  identifies  you,  as  well  as  your  diagnosis, and type of treatment. 
• In  order  to  facilitate  routine  office  operations.  For  example,  exchange  of  information  with  Program Director or BCBA may be necessary to provide treatment. 

For More Information or to Report a Problem 

If  you  have  questions,  would  like  additional  information,  or  want  to  request  an  updated  copy  of  this  notice, you may contact the Director at any time at (812)-606-4413. If you feel your privacy rights have  been violated in any way, please let us know and we will take appropriate action. 

You may also send a written complaint to: 

Department of Health & Human Service, Office of Civil Rights 

Hubert H. Humphrey Building 200 Independence Avenue 

SW Room 509 HHH Building 

Washington, DC 20201