B. ANSCHUETZ PSYCHOTHERAPY PROFESSIONAL CORPORATION We are committed to respecting and protecting your privacy. This statement outlines our policies and procedures with respect to collecting, using and disclosing your personal health information. Collection of your Personal Health Information We collect your personal health information only directly from you, except: a) when you have provided consent to obtain such information from others (e.g., reports of previous assessments or other services); b) where the law requires or allow us to collect information without your consent (e.g., in an urgent situation, where information is needed to prevent potential harm). We collect only that information from you that we believe is reasonably necessary to provide you with services. If we collect information from you for any other purpose (e.g., research), it will be done only with your knowledge and consent. If you decide that you do not want to provide this information or it's not needed for your service, you are completely free to refuse. There will be no impact on your services. Use of Your Personal Health Information Your personal health information is used to provide you with service. This includes using information for service planning, service monitoring, and billing purposes. In addition, we may use some information for program evaluation, quality improvement, trainee education, and risk/ error management. All staff are trained in this practice’s policies and procedures, including prevention of loss of information and prevention of unauthorized access. All staff members are allowed to have access to information about you only on a “need-to- know” basis. A staff person who knows you personally is required to let us know this, and is not allowed to have access to your record unless there is an emergency or unless you give consent. There is a very small chance that client records could be accessed for external auditing, licensing, or accreditation purposes. However, we will not allow any information that identifies you to be used or taken out of these premises for these purposes. All persons involved in such activities are required by law to maintain the confidentiality of any accessed information. Disclosure of Your Personal Health Information With only a few exceptions, your personal health information will not be disclosed to persons outside this office without your consent. The exceptions include circumstances in which disclosure is justified by law and allowed by our profession’s ethical standards (e.g., risk of serious bodily harm; to yourself or by you to someone else i.e., suicide, homicide, need for confidential professional or legal consultation), or required by law (e.g., reporting a child in need of protection; reporting a health professional who has sexually abused a client; a court order to release information from a record). The above exceptions are called “limits of confidentiality.” If there are other limits of confidentiality in your situation, we will identify and discuss them with you before proceeding with your services. When consenting to the disclosure of your personal health information, you may restrict us from sharing all or any part of your personal information. However, if, in your therapists opinion, the information is reasonably necessary for another health service provider to provide appropriate service, we are required by law to inform the other provider that you have refused consent to provide some needed information. Although law allows, under strict conditions, access to personally identifiable health information for research purposes, it is this practice's policy not to allow external researchers access to information that can be identified as belonging to you, unless you consent to such access. Your Right of Access to your Personal Health Information Record With only a few expectations, you have the right to access any record of your personal health information, and to request copies of the information. If you believe that information in your record is not accurate, you may make a written request to correct your record. If your therapist does not agree with the correction you request, you may file a notice of disagreement into your record. Further Information We will speak to you directly and answer any questions you might have regarding this Privacy Statement. If you would like more detailed information at any time, would like to access or ask for a correction of your record, have a concern about our privacy policies and procedures, or have a complaint about the way your privacy has been handled, please do not hesitate to speak or write to Barbara Anschuetz. Complaints may also be addressed to: The Information and Privacy Commissioner of Ontario 2 Bloor Street East, Suite 1400 Toronto, Ontario M4W 1A8 416-326- 3333 or 1-800- 387-0073 Fax: 416-325- 9195 TTY: 416-325- 7539