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Notice of Privacy Practices Regarding Your Protected Health Information

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides consumers with important privacy rights and protection with respect to their health information, including important controls over how their health information is used and disclosed by health plans and health care providers.

Your Choices:

For certain health information, you can tell us your choices about what we share. In these cases, you have both the right and the 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

If you are not able 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 we needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising: we may contact you for fundraising efforts, but you can tell us not to contact you again.

Your Responsibilities

TO treat others with dignity and respect. No violence or concealed weapons will be allowed. If requested, please remove animals during in-home visits.

TO provide accurate and complete information about current or past problems, illness, treatments, and other pertinent information related to physical, mental, or social needs.

TO disclose information related to services received through other agencies.

TO keep appointments. If unable to keep appointment(s), notify the agency of this 24 hrs in advance. Two missed appointments in a row will result in discharge from program. In case of inability to keep appointment(s), all efforts will be done for rescheduling.

TO arrange fee for services when no other reimbursement is available. A sliding scale is available at your request.

If you have any questions or wish to file a complaint or exercise any rights listed in this notice, please contact:

Monarch Immigrant Services

HIPAA Compliance Officer / Privacy Officer

Jason Baker, PhD
Executive Director
Monarch Immigrant Services
4030 Chouteau Ave., Suite 700, Saint Louis, MO 63110

Tel: (314) 645-7800
Fax:(314) 645-7802


MO Dept. of Health & Senior Services: 1-800-392-0210
MO Dept. Of Mental Health
P.O. Box 687 Jefferson City, MO 65102


The right to request an accounting of our use and disclosures of your PHI. You may request a list (accounting) of parties we’ve shared your health information (i.e. from a release form) for six years prior to the date you ask and why. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment, or healthcare operations, or when we share your health information with our business associates, such as arranged transportation for you, disclosures to law enforcement agencies and disclosures authorized by the client.

Personal representation. 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 the authority and can act for you before we take any action.

You also have the right to receive prompt evaluation, care and treatment; To receive these services in the least restrictive environment; To receive these services in a clean and safe setting;

To not be denied admission or services because of race, gender, sexual preference, creed, marital status, national origin, disability, or age;

  • To confidentiality of information and records in accordance with federal and state law and regulation;
  • To be treated with dignity and addressed in a respectful, age appropriate manner;
  • To be free from abuse, neglect, corporal punishment and other mistreatment such as humiliation, threats or exploitation;
  • To consult with a private, licensed practitioner at one’s own expense.


You may complain to us or to the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated or of any other grievances. Reasonable assistance will be given to an individual wishing to file a grievance. While a written complaint is considered a grievance, every effort is made to meet with the client in an informal, non-threatening manner so as to foster a positive outcome and solution. The review will be consistent with principles of due process. Within five business days a written response will be issued to the client summarizing the issue, the discussion, and the resolution to be implemented. Should you have any questions, comments, or complaints you may direct all inquiries to the Privacy Officer listed in this notice.

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Privacy Rule recognizes that circumstances arise where health information may need to be shared to ensure the client receives the best treatment and for other important purposes, such as for the health and safety of the client or others. The Privacy Rule is carefully balanced to allow uses and disclosures or information-including mental health information- for treatment and other purposes with appropriate protections.

We are required by law to protect the privacy of your health information and to notify you if there is a breach of unsecured protected health information. We are also required to provide you this notice, which explains how we may use information about you when we can give out or “disclose” that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice.

Unsecured Protected Health Information and Guidance

Covered entities and business associates must only provide the required notifications in the breach involved unsecured protected health information. Unsecured protected health information is protected health information that has not been rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary in guidance.

Right to Revise Notice of Privacy Practice

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and relations. Upon request, we will provide you with the most recently revised notice on any visit.

How We Use or Disclose Information

We must use and disclose your health information to provide that information: TO you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice, and TO the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. We may use or disclose your health information: No Information will be disclosed without participant permission. Confidential information will remain protected whenever possible. A written consent may be required for information disclosure. Information will not be sold to third parties (solicitors, marketers et al.)

For Treatment. We may use or disclose health information to aid in your treatment or coordination of your care. For example, we may disclose information to other healthcare providers involved in your care.

For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example staff may review records to assess quality and improve services, conduct program evaluation, review qualifications and performance of healthcare providers and to train our staff.

For Payment due to us, to determine eligibility for your coverage. For third party payments, we can use and share your health information to bill and get payment from health plans or other entities. We are also 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:

Help with public health and safety issues. Sharing health information about you for: preventing disease, reporting suspected abuse, neglect, or domestic violence, as well as preventing or reducing a serious threat to anyone’s health or safety.

For Research Purposes. If the research has been approved and has policies to protect your privacy and would require your permission.

Complying with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see what we’re complying with the federal privacy law. Requests may be made by other government or law enforcement.

Responding to lawsuits and legal actions. In response to a court or administrative order, or in response to a subpoena.

Limits to Confidentiality

> Abuse or neglect: we are mandated by law to report any abuse and/or neglect of an elder or child. This includes physical, financial, sexual, and/or emotional abuse.

> Danger to self and others. We have a duty to protect in cases of suicide or homicide risk. Reasonable actions must be taken to inform appropriate authorities or those at risk.

> Minors: if the client is a minor and parents demand disclosure.

> Guardianship: if the client has a guardian, and guardian demands disclosure.

> Court orders: if we receive a valid subpoena or court order.

> For health care fraud and abuse detection or for activities related to compliance with the law.

Bill of Rights

You have the right to inspect and request a copy of your Protected Health Information (PHI), including a readily producible electronic copy that may be used to make decisions about our care, except for psychotherapy notes and certain other circumstances where we may deny your request. You must submit a written request. If a request is denied, you have the right to have your denial review; If you request a copy of the information, we may charge a reasonable, cost-based fee to cover the expense of providing copies, mailing or other supplies associated with your request.

You have the right to request, in writing, restrictions on certain uses and disclosure of your health information. We are not required to grant the request, but we will comply with any request granted.

You have the right to choose how you receive your protected health information. If you wish for us to forward the documents to an alternate address or by some other method of contact, we can do so.

You have the right to ask us to amend your written health information. If errors are found, we will generally amend your information within 60 days of your request and will notify you about it. We are permitted by law to deny your request, but only in circumstances, such as if the health information was not created by s, is not part of the health information we maintain to make decisions about your care, is not part of the health information that you would permitted to inspect or copy, or is accurate and complete. If we accept your amendment, we will place it in your chart, but we will not delete any information that already exists in your record. If you wish to request that we amend your medical information you should contact, in writing, the privacy officer listed in this notice.