Our team of independent clinicians remain forever committed to protecting your privacy. Also for your protection our office
sheet only requests your first name.


10315 Dawson’s Creek Blvd., Building #12 – Suite E
Fort Wayne, IN 46825-1912
This client notification describes how psychological and related medical information about you may be handled and how you can get access to this information. It is to help you understand government guidelines for related laws.

Please review it carefully.
This notice is effective as of August 1, 2008


Our (CVC) Mission:
As in the past, we are committed to protecting your privacy. You may even experience awkward dialogue while standing at our receptionist’s counter. This is our staff’s effort to avoid sharing your personal information in a setting where others are present. We will avoid using your full name for the same reason. Also for your protection our office sign in sheet only requests your first name.

Legal Requirements:
Our team of independent clinicians here at CVC is required by State and Federal laws to maintain the privacy of your Mental Health Information (MHI) and to provide you with a notice of our legal duties and privacy practices with respect to MHI. MHI is information about you, including basic demographic, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. This notification describes how we may use and disclose MHI about you to carry out mental health billing/payment or communication with other providers, or for other specified purposes that are permitted or required by law. The notification also describes your rights with respect to MHI about you.

CVC will not use or disclose MHI about you without your written authorization, except as described in this notification. We reserve the right to change our services, practices, and this notification, and to make the new notification effective for all MHI we maintain. Upon request, we will provide a revised notification to you whenever such occasions are required. The following paragraphs will reflect how we may use or disclose MHI about you.

We will use MHI for treatment. For example: information obtained by CVC will be used to provide appropriate treatment to you. We will document, in your chart, information related to the treatments provided to you in order to monitor treatment effectiveness and ensure continuity of care.

We will use MHI for billing/payment. For example: we will contact your insurer or managed care provider to determine your benefits, whether it will pay for your treatment and the amount of your co-payment responsibility. We will bill you or a third party payer for the cost of treatment provided to you as appropriate. The information on or accompanying the billing may include information that identifies you, as well as the diagnosis for which you are being treated.

We will use MHI for health care operations. For example: CVC may use information in your health record to monitor the performance of the therapist providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the mental health care and support services we provide.  We are likely to use or disclose MHI for the following purposes, as well:

Business associates: There are some services provided to CVC through contracts with business associates. These contracts allow us to provide services to you. An example of this is the company that writes and maintains our billing software. When these support services are contracted for, we may disclose MHI about you to our business associates so they can perform the job we have asked them to do and to bill you or third party payers for mental health and related services rendered. To protect MHI about you, we require the business associate to appropriately safeguard the MHI.

Communication with individuals involved in your care or payment for your care: Mental health professionals, using their professional judgment, may disclose your MHI to a family member, other relative, close personal friend, or any person you and your therapist identify as relevant to your care. Such disclosure will require a Release of Information be signed and witnessed.

Personal communications: We may contact you regarding scheduling information, as in the event of a missed appointment. Automated reminder calls are a courtesy we offer to you, if you have elected on the Client Intake Sheet to receive them. You also have the option on the intake to decline this service.

Public health: As required by law, we may disclose MHI about you to a public health or legal authority charged with preventing injury to yourself or others.

Law enforcement : We may disclose MHI about you for law enforcement purposes as required by law or in response to a valid court order, or to a subpoena approved by you or related guardian.

As required by law: We must disclose MHI when required to do so by law, including cases of child abuse or neglect, or domestic violence. We may disclose MHI about you to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else, or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.

Mental health oversight activities: We may disclose MHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the mental health system, government programs, and compliance with civil rights laws.

Judicial and administrative proceedings: If you are involved in a lawsuit or dispute, we may disclose MHI about you in response to a court or administrative order. We may also disclose MHI about you in response to a subpoena, discovery request, or other lawful purposes, by someone else involved in the dispute, but only if efforts have been made to tell you about the request or we have failed to obtain an order protecting the requested MHI.
We are permitted to use or disclose MHI about you for the following purposes:

Research: We may disclose MHI about you to researchers when their research has been approved by an institutional review board that has received the research proposal and established protocols to ensure the privacy of your information. MHI about your diagnosis, age, gender, and treatment could be used without revealing your identity.

Notification: We may use or disclose MHI about you to notify or assist in notifying a family member, personal representative, or other person responsible for your care, of your location and general condition should it be suspected you are in danger.

Authorizing Records Release:
CVC will obtain your written authorization before using or disclosing MHI about you for purposes other than those provided for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing MHI about you, except to the extent that we have already taken action in reliance on the authorization.



The CVC administrative staff can answer questions regarding privacy practices as well as respond to information requests or complaints.
You have the following rights with respect to MHI about you:

Records Copying & Mailing:
You may request a copy of this notice at any time. Even if you have agreed to receive the notice electronically, you are still entitled to a paper copy. To obtain a paper copy, you may request one in person at CVC. Copying your record is subject to current customary mailing fees and usually requires at least five work days once the request is received in final form. Typically records sent directly to clients are only those for which they have already demonstrated a clear and secure familiarity such that there would be no reason that such a mailing would cause them harm. Thus, clients MHI records are typically handled differently than medical records related to physical illness. Sending requested records to other related, and so designated, providers does not allow for these same documents to also be sent to clients, as well . The following sections address these guidelines in greater detail.

Records Review:
You have the right to review your clinical record for as long as the CVC maintains the MHI. Your chart/the clinical record will usually include both treatment and limited billing records. Client records are not released to clients who have not reviewed that record with their therapist or the Clinical Director if the therapist is unavailable or appoints this substitution. Moreover, clients must demonstrate a safe and accurate understanding of the record at the time of the inspection before a release of any records would be possible. The goal here is to insure no misinterpretation of or potential harm coming to the client through the review of this content. To inspect your MHI, you must send a written request to your therapist or our clinical director at the address listed below using the Client Records Management Request form. This form is available at any CVC site. It is necessary to use this form to process your request. This may require a supervised setting with your therapist, similar to a treatment session which you would be obligated to pay for at the time of service. Insurance cannot be billed for these services. If you wish the clinical director to witness this meeting, you would be responsible to pay for both providers’ time at their respective hourly fees. Supervision will be scheduled as rapidly as possible according to staff availability. CVC will charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant your request (for example: when sending your records to another caregiver or for court-related services). The therapist may deny your request to inspect the copy before it is mailed to your requested provider in certain limited circumstances. If you are denied access to MHI about you or someone under your guardianship, your therapist will provide you with a written explanation. If denied access, you may request that the denial be reviewed by the clinical director.

Amendments to Records:
If you feel that the MHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the MHI. To request an amendment, you must send a written request to your therapist or the clinical director at the address listed at the top of this packet. The form, Client Records Management Request, is available at any CVC site. You must use this form to ensure we receive adequate information to process your request. In addition, you must include a reason to support your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement or disagreement with the decision, and we may give you a rebuttal to your statement.  This statement, and possible rebuttal, will be added to your MHI.

Monitoring Records Releases:
You have the right to receive an accounting of the disclosures we have made of your MHI (after August 1, 2008, for most purposes other than treatment, or billing operations). The accounting will exclude disclosures we have made directly to you and disclosures for scheduling purposes. The right to receive an accounting is subject to certain other expectations, restrictions, and limitations. To request an accounting, you must submit your request in writing to your therapist or our director (address listed above). Forms for this are available at any CVC site. You must use this form to ensure we receive adequate information to process your request. Your request must specify a time period, which may not be longer than six years. We will notify you of the cost involved, which must be paid prior to the service being rendered and you may choose to withdraw or modify your request at any time.

Need Help (?):
If you require more information or need to report a problem, you may contact our administrative staff or director, or you may mail us a letter (address listed above). If you believe your privacy rights have been violated, you can file a complaint with the director or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. If you believe your concerns were not adequately addressed, and/or that your privacy rights have actually been violated in anyway, you can contact the Department of Health and Human Services at 303-844-2024.