WILPOWER, INC. NOTICE OF PRIVACY PRACTICES

AND MEMBER RIGHTS

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY

BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your health information is private and WilPower, Inc. will only release confidential information about you in accordance with Illinois and federal law. This notice describes our policies about the use of your records and contains your rights regarding your records and health information.

If you have any questions about this notice or your rights contact the WilPower, Inc. Privacy Officer, Eva Martinez-Klich, Program Director, (847) 501-4718 x 13.

Use and Disclosure of Personal Health Information

What is Personal Health Information (PHI)? It is health, payment, treatment and descriptive information that identifies you personally.

To give you good care, we may need to share your confidential information with others outside of WilPower, Inc. in the following circumstances:

Treatment. We may use or disclose treatment information about you to provide, coordinate, or manage your care and services. Example: Information about your use of services at WilPower may be shared with a therapist, doctor, employment counselor, etc.

Payment. With your written consent, WilPower will use your information to obtain payment for the treatment and services we give. Example: Service information that we give to insurance companies or Medicaid and Medicare.

Healthcare Operations. We may use information about you during our regular program evaluation processes; during program, record and financial audits; during staff training; or during organization planning, development and routine management.

Information We May Disclose Without Your Consent. Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:

Emergencies. Information may be shared to address the immediate emergency you may face. Example: We may give your medication information to an Emergency Medical Technician.

Follow Up Appointments/Care. We may contact you to inform you of future appointments; about treatment alternatives; or other health-related benefits and

services that may be of interest to you. We will leave appointment information on your answering machine unless you tell us not to.

As Required by Law. This includes:

When we are served a subpoena, court order, or are otherwise mandated to provide public health information, as in cases of communicable disease or suspected abuse and neglect (child abuse, elder abuse, or institutional abuse).

We must give sufficient information about you so a coroner, medical examiner or funeral director can perform their duties.

We may give information about you to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. We are also required to share information, if requested, with the U.S. Department of Health and Human Services to determine our compliance with federal laws related to health care and to Illinois state agencies that fund our services.

If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an someone may be in immediate danger.

WilPower, Inc. is a not for profit agency and solicits contributions to raise money. We may contact you for a donation.

Your Rights

You have the following rights regarding your personal health information under Illinois and federal law:

Request Restrictions of the Use of your Records. You must write a request (to the WilPower Privacy Officer) that describes to us what information to restrict, and with whom it is restricted. WilPower is not required to grant your request if we believe it is in the best interests of the agency.

Copy of Record. You have the right to look at or get copies of the records that WilPower, Inc. has in your file. Your request must be in writing to the WilPower Privacy Officer. We may deny your request, but will do so in writing and explain why we made the decision and how you can appeal it. We may charge you a reasonable fee for copying and mailing your record.

Release of Records. You may consent in writing to the release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Contacting You. You may request that we send you information to the address you choose, or by another method (that we are able to carry out and we believe will accomplish our goal of informing you).

Amending Record. If you believe that something in your record is incorrect or incomplete, you may request we amend it. You must ask for the Request to Amend Health Information form. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response will be added to your record.

Accounting for Disclosures. You may request an accounting of any disclosures we have made related to your confidential information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the WilPower, Inc. Privacy Officer. We will notify you of the cost involved in preparing this list.

Questions and Complaints. If you have any questions, or wish a copy of this Policy or have any complaints you may contact the WilPower Privacy Officer in writing at our office. You also may complain to the Secretary of U.S. Department of Health and Human Services if you believe WilPower, Inc. has violated your privacy rights. We will not retaliate against you for filing a complaint.

Changes in Policy. WilPower, Inc. reserves the right to change its Privacy Policy based on the needs of the agency and changes in state and federal law.