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Notice of Privacy Practices Summary

Effective: 09/01/2013

This is a brief summary of Chestnut Ridge Counseling Services, Inc. Notice of Privacy Practices. Save or print this summary using the buttons in the top-right corner. The entire Notice is available at the bottom of this page.

Chestnut Ridge Counseling Services, Inc. (CRCSI) is committed to protecting the confidentiality of your medical information and is required by law to do so. The Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We ask for your consent to use and disclosure your PHI, as outlined in our Notice of Privacy Practices, by asking you to sign the Consent for Treatment form regarding your care. Generally, unless specifically allowed by state or federal regulations without an authorization, CRCSI will seek a signed authorization from a consumer or personal representative before disclosing PHI to a third party.


CRCSI may use or disclose your protected health information as follows:

Uses and Disclosures with Your Permission:
Uses and disclosures of PHI will generally only be made with your written permission, called a “Release of Information” You have the right to revoke a Release at any time.

For Treatment:
CRCSI will use and disclose your PHI to provide and coordinate your health care and any related services. CRCSI may also disclose your PHI to another health care provider working outside of CRCSI for purposes of your treatment.

For Payment:
CRCSI may use and disclose PHI about you for the purpose of determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company or a third party payer, or its agent. You may request restriction of this if paying for your own services.

For Health Care Operations:
CRCSI may use and disclose PHI about you in order to support quality improvement and other business activities of our organization. These uses and disclosures are necessary for our operations and ensure the quality of care received by our patients.

Other Uses and Disclosures Provided by Law without Authorization:
CRCSI may use and disclose PHI about you for other purposes and to other individuals and entities without a signed authorization, as provided by state and federal law. This includes but is not limited to court orders, child abuse reporting, adult protective services reporting, etc.


You have the following rights regarding your protected health information (PHI):

  • Right to Inspect and have a paper/electronic Copy
  • Right to Request an Amendment
  • Right to a Paper Copy of Notice
  • Right to be notified of breach of unsecured PHI
  • Right to Request Confidential Communications
  • Right to Request Restrictions
  • Right to an Accounting of Certain Disclosures

To file a violation complaint with our office, contact the Privacy Officer 100 New Salem Road, Uniontown, PA 15401. All complaints must be made in writing. You may also file a violation complaint with Secretary of the Department of Health and Human Services.


In addition to this summary, you are being offered a full detailed copy of the Notice of Privacy Practices. You may also at any time receive a copy by asking for one when you are at our offices, request for one to be mailed to you, or by visiting our website at You may contact the CRCSI HIPPA Privacy Officer or Security Officer with any questions or for clarification of procedures and practices.

Detailed Notice of Privacy Practices

A detailed notice of CRCSI’s privacy practices are available here.

Effective: 09/01/2013