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Your Information, Your Rights, Our Responsibilities: 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.

YOUR RIGHTS: When it comes to your health information you have certain rights. This section explains your rights and some of our responsibilities to help you.
1. Get an electronic or paper copy of your records:
-You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.’
-We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable cost-based fee.
2. Ask us to correct your medical record:
-You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
– We may say “no” to your request, but we will tell you why in writing within 60 days.
3. Request confidential communications:
-You can ask us to contact you in a specific way(for example, home or office phone) or to send email to a different address.
-We will say “yes” to all reasonable requests.
4. Ask us to limit what we use or share:
-You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
-If you pay for a service or a health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment of our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
5. Get a list of those with whom we have shared information:
-You can ask for a list(accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
-We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures(such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
6. Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive this notice electronically. We will provide you with a paper copy promptly.
7. Choose someone to act for you:
-If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
-We will make sure the person has this authority and can act for you before we take any action.
8. File a complaint if you feel your rights are violated:
-You can complain if you feel we have violated your rights by contacting us by calling Cindy A. Stear at 815-389-0123 or sending her a letter at 1047 Cannell Court, Rockton, IL 61072.
-You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
-We will not retaliate against you for filing a complaint.

For certain health information, you can tell us your choices about what we share:
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
-Share information with your family, close friends, or others involved in your care
-Share information in a disaster relief situation
-Include your information in a hospital directory
-Contact you for fundraising efforts.
If you are unable to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safery.
In these cases we will never share your information unless you give us written permission:
-Marketing purposes, Sale of your information, Most sharing of psychotherapy notes.
In case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information? We typically use or share your health information in the following ways:
1. Treat you: We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor for your overall health condition.
2. Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: we use healthy information about you to manage your treatment and services.
3. Bill for your services: We can use and share your health information to bill and get payment for health plans and other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways -usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

We require your written authorization to disclose information related to HIV/AIDS and/or substance abuse.

No one will be denied access to services due to inability to pay, and there is a discounted/sliding fee schedule available based on family size and income.

Connections Therapy Center will not discriminate in the provision of health care services to an individual:

  1. Because the individual is unable to pay for the health care services;
  2. Because payment for those services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP); or
  3. Based upon the individual’s race, color, sex, age, national origin, disability, religion, gender identity or sexual orientation.

Connections Therapy Center

1047 Cannell Court
Rockton, IL 61072

p: 815-957-0115
f: 866-813-6462

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