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


At Professional Services Group (PSG) and Community Impact Programs (CIP), we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information 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. This Notice is effective as of September 1, 2023 and applies to all protected health information as defined by federal regulations.

Understanding Your Health Record/Information

Each time you have contact with PSG/CIP, a record of your visit is made. Typically, this record contains your symptoms, diagnoses, treatment notes, 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;
  • Means of communication among the health professionals who contribute to your care;
  • 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.

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 Rights Regarding Your Health Information

  • You have the right to inspect and receive a copy of your Protected Health Information (PHI). A request to look at or receive a copy of your records can be made to your therapist or worker. There may be a charge for copies of your PHI.
  • You have the right to ask us to change the information we have if you believe it is incorrect or incomplete. Your request must be in writing, signed, and submitted to PSG/CIP. If we deny your request, we will give you an explanation in writing.
  • You have the right to request a restriction or limitation on the use and disclosure of your health information. To make a request, you must tell us what information you want to limit, if you want to limit our use, disclosure, or both, and who you want the limit to apply to. Your request must be signed by you or your personal representative. We are able to deny your request but will attempt to accommodate your request. If we make the decision to terminate such an agreement, we will notify you of the termination.
  • With some exceptions, you have the right to receive an accounting of disclosures of your PHI. Your request must be in writing and signed by you or your personal representative and submitted to PSG/CIP and must specify the timeframe in which the disclosures were made.
  • You have the right to request that we communicate with you in a certain way. For example, you may request that we only contact you via email. You must submit your request in writing to PSG/CIP.
  • You have the right to receive a paper copy of this Notice even if you have already received it electronically.
  • Additional uses and disclosures of your PHI will only be made with your written authorization. You have the right to revoke your authorization at any time.
  • You may submit any complaints with respect to violations of your privacy rights to PSG/CIP. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services if you feel your rights have been violated.

Our Responsibilities

Professional Services Group/Community Impact Programs is required to:

  • Maintain the privacy of your health information;
  • Notify you if a breach of your health information occurs;
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you;
  • 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 locations.

Circumstances Under Which Health Information Will be Used or Disclosed

To Provide Treatment

  • We may disclose your health information to others who provide care to except in emergency situations, we will make reasonable efforts to get your permission prior to making disclosures outside PSG/CIP for treatment purposes.

To Obtain Payment

  • We may use your health information to collect reimbursement from your health insurance. We may also contact your insurance carrier to receive authorization for services. We will also provide your health information to the credit bureau if you fail to pay for services rendered.

For Healthcare Operations:

  • We may use and share your PHI for our own healthcare operations, which may include planning, management, quality assurance, and improvement activities. For example, we may use your health information to monitor the skills of our therapists or to review health outcomes within our organization.

For Appointment Reminders

  • We may use your health information to contact you for appointment reminders or other information about your appointment.

In the Event of a Serious Threat to Health or Safety

  • Consistent with laws and ethical standards of conduct, we will disclose your personal health information, if in good faith, we believe that such a disclosure is necessary to prevent or lessen a serious and imminent threat to your safety, the safety of another, or the public. We will also disclose your health information to coroners/medical examiners for purposes of determining your cause of death or for other duties authorized by law.

When Legally Required

  • We may disclose your health care information when ordered to do so by a judge or to comply with federal, state, or local law enforcement.
  • If the Department of Health and Human Services (HHS) investigates privacy violations, we may share your information with HHS, if requested.

To Conduct Health Oversight Activities

  • We must disclose your PHI to a health oversight agency for activities that are required by federal, state, or local law. This may include audits, civil, administrative or criminal proceedings, inspections, or disciplinary action.

Public Health Risks

  • As authorized by law, we may disclose your health information to public health authorities whose official responsibilities include the following:
    • To prevent or control disease, injury, or disability
    • To report births and deaths
    • To report child abuse or neglect
    • To report reactions to medications or problems with products
    • To notify people of recalls of products they may be using
    • To notify people who may have been exposed to a disease or be at risk for contracting or spreading a disease

For Specialized Government Functions

  • We may disclose your health care information to facilitate specialized government functions relating to the military, national security, intelligence activities, or protective services for the

Law Enforcement

  • We may disclose your PHI to a law enforcement official if required or allowed by law. We may also disclose your information that is not part of your health record for the following reasons:
    • To identify or locate a suspect, fugitive, material witness, victim of a crime, or missing person
    • To disclose a death that we believe may be the result of criminal conduct
    • To disclose criminal conduct at our clinic
    • In emergency situations to report a crime or the location of a crime or victims


  • We may disclose your health care information to your employer if your treatment is at the request of your employer, related to workman’s compensation or an evaluation. We will provide you with written notice of such a disclosure. Any other disclosure to your employer will only be made if you sign an authorization for the release of that information.

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 mail a revised notice to the address you’ve supplied us, or if you agree, we will e-mail the revised notice to you.

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 disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem

If you have questions or would like additional information, you may contact PSG/CIP’s Privacy Officer, Leah Featherstone, Psy.D. at (262) 652-2406.

If you believe your rights have been violated, you can file a complaint with the practice’s Grievance Specialist, 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 Grievance Specialist, Privacy Officer or the Office for Civil Rights. The address for the Office for Civil Rights 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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