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Privacy Policy and Notice of Health Information Practices
Catherine Jantzen, LLC
6334 Constitution Dr., Fort Wayne, IN 46804 | p (260) 213-1300 | f (260) 782-3215 Effective Date: January 1, 2014



This updated notice is effective January 1, 2014 and replaces previous versions provided to you by Catherine Jantzen LLC.



We at Catherine Jantzen, LLC (CJLLC) are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the identifiable patient health information (this information is “protected health information” and is referred to herein as “PHI”) that we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. We will only use or disclose your PHI as permitted or required by applicable state and federal laws. This Notice applies to your PHI in our possession, including the medical records received or generated by us.

CJLLC understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how CJLLC will use and disclose your PHI. This Notice applies to the delivery of health care by CJLLC and its staff. This Notice also applies to the utilization review and quality assessment activities internally by CJLLC, certain governmental agencies and those by your insurance carrier.

Understanding Your Health Record/Information Permitted use or Disclosure

Each time you visit Catherine Jantzen, LLC, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

  • Basis for planning your care and treatment. For example, we will use and disclose your PHI to your therapist, supervising physician, consulting physician(s), and other health care providers who have a legitimate need for such information in your care and continued treatment.

  • Means of communication among the many health professionals who contribute to your care. CJLLC will share certain information to coordinate your treatment such as appointment scheduling with us and other health care providers such as name, address, employment, insurance carrier, etc.

  • Legal document describing the care you received.

  • Means by which you or a third-party payer can verify that services billed were actually provided.

  • A tool in educating health professionals.

  • A source of data for medical research.

  • A source of information for public health officials charged with improving the health of this state and the nation.

  • A source of data for our planning and marketing.

  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

  • A tool for Court assessments such as Custody Evaluations, Parenting or Visitation Assessments, confidentiality is waived and any

    information provided, including oral statements, will be used in the preparation of a report to the Courts with copies of the reports provided to both parties’ attorneys. Information obtained may be shared with the other party in verifying information received or to give them an opportunity to respond to any allegations of wrongdoing.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

You have the right to:

  • Obtain a paper copy of this notice of information practices upon request,

  • Inspect and copy your health record as provided for in 45 CFR 164.524,

  • Amend your health record as provided in 45 CFR 164.528,

  • Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,

  • Request communications of your health information by alternative means or at alternative locations,

  • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and

  • Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

    Although your health record is the physical property of Catherine Jantzen, LLC, the information belongs to you. Subject to certain limited exceptions, you have the right to access your PHI and to inspect and receive a copy of your PHI as long as we maintain the data. If CJLLC denies your request for access to your PHI, CJLLC will notify you in writing with the reason for the denial. For example, you do not have the right to psychotherapy notes or to inspect the information which is subject to law prohibiting access. You may have the right to have this decision reviewed. You will be charged a reasonable copying fee in accordance with applicable federal or state law.


You have the right to amend your PHI for as long as CJLLC maintains the data. You must make your request in writing to CJLLC, including your reason to support the requested amendment. However, CJLLC will deny your request for amendment if CJLLC did not create the information, if the information is not part of the designated record set, if the information would not be available for your inspection (due to its condition or nature), or if the information is accurate and complete. If CJLLC denies your request for changes in your PHI, CJLLC will notify you in writing with the reason for the denial. You may ask that CJLLC include your request for amendment and the denial any time that CJLLC subsequently discloses the information that you wanted changed. CJLLC may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.


You have a right to receive an accounting of the disclosures of your PHI that CJLLC has made, except for the following disclosures: To carry out treatment, payment or healthcare operations; To you; To persons involved in your care; For national security or intelligence purposes; or To correctional institutions or law enforcement officials. You must make your request for an accounting in writing to CJLLC. You must include the time period of the accounting, which may not be longer than six (6) years. In any given twelve (12) month period, CJLLC will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting.


You have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or health care operations functions or to prohibit such disclosure. However, CJLLC will consider your request but is not required to agree to the requested restrictions. Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require authorization. Other uses and disclosures not described in this Notice will be made only with your signed authorization.


You also have the right to request a restriction on disclosure of your PHI to a health plan (for purposes of payment or health care operations) in cases where you paid out of pocket, in full, for the items received or services rendered.

You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that CJLLC only contact you at work or by mail.


You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.


Our Responsibilities

Catherine Jantzen, LLC is required to:

  • Maintain the privacy of your health information,

  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about


  • Abide by the terms of this notice,

  • Notify you if we are unable to agree to a requested restriction, and

  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative



We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide you with the revised Notice at your first visit following the revision of the Notice in cases where it makes a substantial change in the Notice.


We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or to disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization. For those participating in alcohol or substance abuse treatment oral revocation of an authorization is allowed.

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment.

For example: Information obtained by a therapist, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your therapist will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the therapist will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this treatment.

We will use your health information for payment.

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.


We will use your health information for regular health operations.

For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.


Business associates: There are some services provided in our organization through contacts with business associates. Examples include mandatory physician review of diagnostic intake interviews, treatment plans, case review, and all Medicaid services, certain laboratory tests, and computer program maintenance. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered where applicable. To protect your health information, however, we require the business associate to appropriately safeguard your information.


Directory: We do not issue a directory of patients as we are an out-patient office only. We do not release patient information except as provided by law or consent.


Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.


Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.


Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. CJLLC will obtain your written authorization to use or disclose your PHI for research purposes when required by HIPAA.


Funeral directors: We are not an inpatient facility and will not disclose information to funeral directors.


Organ procurement organizations: We are not an inpatient facility and will not disclose information to organ procurement


Marketing: We may contact you to provide appointment reminders, information about treatment alternatives, other health-related benefits and services that may be of interest to you or to mail satisfaction surveys to you to determine your level of satisfaction with the services being provided.


Food and Drug Administration (FDA): We are not an inpatient facility and will not disclose information to the FDA.


Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with

laws relating to workers compensation or other similar programs established by law.


Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.


Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.


Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena and Court order where required.


Other Uses: Any uses or disclosures that are not for treatment, payment or operations and that are not permitted or required for public policy purposes or by law will be made only with your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.


Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

The state law of Indiana is more stringent than the Health Information Portability and Accountability Act (HIPAA) in several areas. Certain federal laws also are more stringent than HIPAA. CJLLC will continue to abide by these more stringent state and federal laws.


CJLLC does not currently participate in Health Information Exchange. As permitted by law, your health information can be shared with a Health Information Exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. If in the future we decide to participate, the data submitted would be accessible by only approved providers and individuals (e.g., physician office and hospital personnel) for the purposes of treatment, payment and/or health care operations.


Records Retention and Information Sharing: To ensure continuity of care and medical history Catherine Jantzen, LLC will retain your records for a minimum of seven (7) years. PHI may be shared, with proper consent or by law, through the US Mail, facsimile transmission (only to secure locations as defined by HIPAA), or by email if you request. If requesting information by email, a waiver regarding the risks involved utilizing this method of sharing will be obtained from you for your file. CJLLC maintains records either in paper form or computer form behind at least two (2) locks, computers are all passworded and accessible only to those needing the information to perform their duties, and uses encrypted transmission for emails and electronic data sets for insurance claim filing.


Breach of Unsecured PHI: If a disclosure in violation of the Privacy Rule of unsecured PHI occurs, CJLLC will perform a risk assessment. Unless that assessment determines that there is a low probability that the PHI has been compromised, or another exception applies, CJLLC is required to notify the individual that a breach of unsecured PHI has occurred as soon as reasonable possible after CJLLC takes a reasonable time to investigate the circumstances surround the breach, but no longer than sixty (60) days after the discovery of the disclosure.


For More Information or to Report a Problem

If have questions and would like additional information, you may contact the practice’s Privacy Officer, Catherine Jantzen, at (260) 213-1300 or by writing to her at 6411 Constitution Dr., Fort Wayne, IN 46804.


If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:


Office for Civil Rights

U.S. Department of Health and Human Services 200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201 


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