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Terms and Policy

Privacy Notice
Notice of Diana Zilly LLC Policies and Practices to Protect the Privacy of Your Health Information

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Diana Zilly LLC may use or disclose your protected health information (PHI) for treatment, payment, and health care operation purposes with your written authorization. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.

“Treatment, Payment, and Health Care Operations”
Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility of coverage.
Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within our office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.

“Authorization” is your written permission to disclose confidential mental health information. All authorization to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization
Diana Zilly LLC may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances, when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization form from you before releasing this information. We will also need to obtain an authorization before releasing your Progress Notes. Progress Notes are notes we have written about our conversations during private, group, joint, or family counseling sessions. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Progress Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization
Diana Zilly LLC may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse – If we have reasonable cause to believe a child known to us in our professional capacity may be an abused child or a neglected child, we must report this belief to the appropriate authorities.

Adult and Domestic Abuse – If we have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, we must report this belief to the appropriate authorities.

Health Oversight Activities – We may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment, and the records thereof, such information is privileged under state law, and we must not release such information without a court order. We can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization or court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You must be informed in advance if this is the case.

Serious Threat to Health or Safety – If you communicate to us a specific threat of imminent harm against another individual, or if we believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.

Worker’s Compensation – Diana Zilly may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regarding fault.

IV. Patient’s Rights and Psychotherapist’s/Psychiatrist’s Duties

Right to Request Restrictions- You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means at Alternative Locations- You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. On your request, we will send your bills to another address.)

Right to Inspect and Copy-You have the right to inspect or obtain a copy of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record and Progress Notes. On your request, we will discuss with you the details of the request for access process.

Right to Amend- You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Right to a Paper Copy- You have the right to obtain a paper copy of the notice from Diana Zilly upon you request, even if you have agreed to receive the notice electronically.

Psychotherapist’s/Psychiatrist’s Duties:
We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

Diana Zilly LLC reserves the right to change the privacy policies and practices described in this notice. However, I am required to abide by the terms currently in effect unless we notify you of such changes.

If Diana Zilly LLC revises policies and procedures, she will provide you with a revised notice either at your next regularly scheduled meeting or by mail.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact me at 630-479-4676.

If you believe that your privacy rights have been violated and wish to file a complaint with us, you may send your written complaint to us at Diana Zilly LLC, 1555 Naperville/Wheaton Road, 206C, Naperville, IL 60563.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on January 01, 2015.

Diana Zilly LLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by giving you a copy of revisions
( Type Full Name )
Client Bill of Rights and Informed Consent
Contact Information: My name is Diana Zilly, MA, MS, LCPC,CH. My pratice is located at 1555 Naperville/Wheaton Road, Suite 206, Naperville, IL 60563. Phone: 630-479-4676. Consultation is by appointment only.

Education and Training:
I am a Licensed Clinical Professional Counselor in Illinois, practicing in the specialization of hypnotherapy. I provide mental health counseling. I have a Master of Arts degree in Psychology, with a major in Human Development, from National-Louis University. I have a Master of Science degree in Mental Health Counseling from Walden University. 

As a clinically licensed mental health counselor, I am able to make a mental health diagnosis, and provide you with appropriate treatment within my boundaries of competence, referring out as necessary. I do not prescribe medication and will advise you to speak with your doctor about medication-related questions and concerns.

In the event my services are terminated, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse counseling services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions, and may assert any right without retaliation. I expect clients to treat me with respect and courtesy, and I have the right to conduct sessions free of physical, verbal, or sexual abuse, and free of any type of harassment at any time whether in session, by phone, or by electronic communication. 

Fees: Clients follow the fee schedule and payment terms agreed to at the time of service. There will be a $50 cancellation fee unless you notify the office more than 24 hours in advance (except in cases of emergency or severe weather). This fee will automatically be assessed to your account. Clients pay all fees relating to returned checks including my $30 returned check fee assessed to your account. I reserve the right to increase these fees at any time in response to increases in overhead costs, bank fees, and other costs of conducting business.  Payments for sessions are non-refundable, non-transferable. Payment is due when services are rendered.

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. I will protect your counseling records to the extent permissible by law. Should you request records regarding your therapy, I will provide you with a summary of your treatment.

Communication: Clients are expected to use the HIPAA compliant patient portal to send me messages and not use email or text for personal communication with me. Clients will receive appointment reminders via text and email that are automatically generated from the patient portal system. 

Insurance: I will either bill your insurance or you will pay a cash rate. Should you decide to try to bill your insurance for services at a cash rate, you will not hold Diana Zilly or Diana Zilly LLC liable as your actions could be construed as insurance fraud. Signing this form indicates your understanding and agreement to this. You are responsible for paying any balance due on your account not covered by insurance.

My Approach: I practice client-centered counseling that focuses on developing each person's ideal sense of wellness and healing. This eclectic approach is supported by my background in psychology, human development, and counseling, with emphasis on the development of personal resilience. Each client is treated with respect, compassion, and encouragement.

What to Expect During Counseling: Each person has his own unique experience during counseling. It is perfectly normal to feel a range of thoughts and emotions, and I will help you process whatever you experience. Everything you experience will feel natural and within a normal range of typical feelings that you might feel from day to day.

Client Responsibility: I expect my clients to be honest with me about their health, medical history, and the prescription drugs that they are currently taking. Clients must also arrive at their appointments free from the influence of illegal drugs and alcohol, otherwise treatment will be refused and their fee still assessed. It will be treated the same way as a last-minute cancellation. Clients are responsible for attending their scheduled sessions and being courteous and respectful of our scheduled time. I reserve the right to terminate my relationship with clients who are routinely late, habitually miss appointments, or conduct themselves in an inappropriate manner, such as subjecting me to physical, verbal, or sexual harassment, bullying, or other aggressive behavior. If this behavior occurs during a session, I will end the session and the client will be responsible for payment of that session. Clients may log into the portal at any time to review this document and their privacy notice. 
Informed Consent: I have read and I understand this Client Bill of Rights. I understand that there are no absolute, guaranteed results promised from counseling. I release Diana Zilly and Diana Zilly LLC from any liability in regard to this.

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