Health Insurance/EAP:
We are in-network with many health insurance plans and Employee Assistance Programs (EAP’s). Please verify your coverage and benefits, as you will be responsible for fees that your insurance does not cover.
Self-pay:
All fees are payable in advance or due at the time of service. For out-of-network services, we will provide you a superbill that you can submit to your insurance company to request reimbursement. (Discounts do not apply.) This is an especially good option if your health insurance plan has a high deductible, or if you are concerned about privacy and control of your records.
Cancellation Policy:
Your time is valuable, and so is ours, so please understand that our therapists have a strict policy of requiring at least 24 hours’ (one full business day) notice of cancellation. Advance notice will allow us time to schedule the allotted time for someone else in need. There is a fee for late cancellations and no-shows.
Privacy policy
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.
Yurk Counseling Services LLC (YCS) is required by law to maintain the privacy of your health information.
YCS is also required to provide you with a notice that describes YCS’s legal duties and privacy practices and your privacy rights with respect to your health information. We will follow the privacy practices described in this notice.
If you have any questions about any part of this Notice or if you want more information about the privacy practices of YCS, please contact:
Tina Gray-Siebers, PhD, LPC, CCATP Yurk Counseling Services LLC Phone: 920.287.0406 Fax: 920.287.0410
We reserve the right to change the privacy practices described in this notice in the event that the practices need to be changed to be in compliance with the law. We will make the new notice provisions effective for all the protected health information that we maintain.
If we change our privacy practices, we will have them available upon request. Notification of change will also be posted at the location of service.
How YCS May Use or Disclose Your Health Information for Treatment, Payment, and Health Care OperationsThe following categories are examples of the ways that YCS may use and disclose your health information. We will explain what we mean and present some examples.
Treatment
We may use or disclose your health care information in the provision, coordination or management of your health care. Our communications to you may be by telephone, cell phone, e mail, patient portal, or by mail. For example we may use your information to call and remind you of an appointment or to refer your care to another provider. If another provider requests your health information and they are not providing care and treatment to you we will request an authorization from you before providing your information.
Payment
We may use or disclose your health care information to obtain payment for your health care services. For example, we may use your information to send a bill for your health care services to your insurer.
Health Care Operations
We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning, and compliance with the law. If the activities require disclosure outside of our health care organization we will request your authorization before disclosing that information.
How YCS May Use or Disclose Your Health Information Without Your Written Authorization
The following categories are examples of the ways that YCS may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and present some examples.
- Required by Law We may use and disclose your health information when that use or disclosure is required by law. For example, we may disclose medical information to report child abuse or to respond to a court order.
- Public Health We may release your health information to local, state, or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases, and reporting problems with products and reactions to medications to the Food and Drug Administration.
- Victims of Abuse, Neglect, or Violence We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect, or violence relating to children or the elderly.
- Health Oversight Activities We may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system.
- Judicial and Administrative Proceedings We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order. Under most circumstances when the request is made through a subpoena, a discovery request or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
- Law Enforcement We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person or complying with a court order or other law enforcement purposes. Under some limited circumstances, we will request your authorization prior to permitting disclosure.
- Research Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to cure a heart disease or whether a certain treatment is working better than another.
- To Avert a Serious Threat to Health or Safety We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
- Workers’ Compensation Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization. These programs may provide benefits for work related injuries or illness.
- Health Information We may use or disclose your health information to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you. If Wisconsin law materially limits or prohibits any of the uses and disclosures described above, each such use and disclosure described above must reflect the more stringent law.
When YCS is Required to Obtain an Authorization to Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy will require your authorization. If you do authorize us to use or disclose your health information, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, although we will be unable to take back any disclosures we have already made with your permission.
Your Health Information Rights
- Inspect and Copy Your Health Information You have the right to inspect and obtain a copy of your health care information. You have the right to request that the copy be provided in an electronic form or format. If the form and format are not readily producible, then we will work with you to provide it in a reasonable electronic form or format. This right of access does not apply to psychotherapy notes, which are maintained for the personal use of a mental health professional. We may charge you a reasonable fee to cover our expenses for copying your health information.
- Request to Correct Your Health Information You have a right to request that YCS amend your health information that you believe is incorrect or incomplete. For example, if you believe the date of a session is incorrect; you may request that the information be corrected. We are not required to change your health information, and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. You must also provide a reason for your request.
- Request Restrictions on Certain Uses and Disclosures You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a disclosure restricted to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you, or the person other than the health plan on your behalf, has paid the covered entity in full.
- Receive Confidential Communications of Health Information You have the right to request that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. We must accommodate reasonable requests.
- Receive a Record of Disclosures of Your Health Information You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made.
- Obtain a Paper Copy of This Notice Upon your request, you may at any time receive a paper copy of this notice even if you earlier agreed to receive this notice electronically.
- Notified of a Breach We are required by law to maintain the privacy of protected health information, provide you with notice of our legal duties and privacy practices with respect to protected health information, and notify you following a breach of unsecured protected health information.
- Complaint If you believe your privacy rights have been violated, you may file a complaint with:
