Download a PDF copy of WomenSafe Notice of Privacy Sept 2013

Download our Non-Discrimination Policy


WomenSafe, Inc.
12041 Ravenna Road
Chardon, Ohio 44024

Effective Date: September 13, 2013, updated December 18, 2015
Revised to reflect the 2013 HIPAA/HITECH Omnibus Final Rule.


If you have any questions about this Notice, please contact:

Andrea Gutka, Privacy Officer, 440-286-7154 x224
Terra Thorpe, Security Officer, 440-286-7154 x225


At WomenSafe, we understand that information about your health is personal. We are committed to protecting your health information and safeguarding that information against unauthorized use or disclosure. This Notice will tell you how we may use and disclose your health information. It also describes your rights and the obligations we have regarding the use and disclosure of your health information.

We are required by law to: 1) maintain the privacy of your health information; 2) provide you Notice of our legal duties and privacy practices with respect to your health information; 3) to abide by the terms of the Notice that is currently in effect; and 4) to notify you if there is a breach of your unsecured health information.

You may receive a copy of any revised notices by mailing a request to WomenSafe to the contact listed above.


When you receive services paid for in full or part by the Board, we receive health information about you. We may receive, use or share that health information for such activities as payment for services provided to you, conducting our internal health care operations, communicating with your healthcare providers about your treatment and for other purposes permitted or required by law. The following are examples of the types of uses and disclosures of your personal information that we are permitted to make:

Your Authorization – Except as outlined below, WomenSafe, Inc. will not use or disclose your protected health information for any purposes unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless WomenSafe, Inc. has acted in reliance on the authorization.

Uses and Disclosures for Treatment – WomenSafe, Inc. will make uses and disclosures of your protected health information as necessary for your treatment. For example clinical and direct care staff members involved in your care will use information in your clinical record and information that you provide about your situation and issues to plan a course of treatment for you that will best meet your needs.

Family and Friends Involved in Your Care – With your approval, WomenSafe, Inc. may from time to time disclose your protected health information to designated family members, friends, and others who are involved in your treatment in order to facilitate the person’s involvement in your care. If you are unavailable, incapacitated, or facing an emergency medical situation and it is determined that a limited disclosure may be in your best interest, limited protected health information may be shared with such individuals without your approval. WomenSafe, Inc. may also disclose limited health information in a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates – Certain aspects and components of WomenSafe, Inc.’s services are performed through contracts with outside persons or organizations, such as auditing and quality assurance review, etc. At all times, it may be necessary to provide certain aspects of your protected health information to one or more of those outside persons or organizations that assist WomenSafe operations. In all cases, these business associates are required to appropriately safeguard the privacy of your information.

Payment – We may use or disclose information about the services provided to you and payment for those services for payment activities such as confirming your eligibility, obtaining payment for services, managing your claims, utilization review activities and processing of health care data.

Health Care Operations – WomenSafe may use or disclose, as needed, your protected health information in order to support business activities. We may use your health information to train staff, manage costs, conduct quality review activities, perform required business duties, and improve our services and business operations. Research: In limited circumstances, WomenSafe may use and disclose your protected health information for research purposes. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by the Institutional Review Committee, which oversees the research, or by representatives of the researchers that limit their use and disclosure of client information.

Confidentiality of Alcohol and Drug Abuse Patient Records – The confidentiality of alcohol and drug abuse client’s records maintained by WomenSafe, Inc. is protected by federal law and regulations. Generally, WomenSafe Inc., may not disclose any information identifying you as an alcohol or drug abuser unless a) you consent in writing, b) the disclosure is made to medical personnel in a medical emergency, or c) to qualified personnel for research, audit, or program evaluations.

Other Uses and Disclosures – We may also use or disclose your personal health information for the following reasons as permitted or required by applicable law: To alert proper authorities if we reasonably believe that you may be a victim of abuse, neglect, domestic violence or other crimes; to reduce or prevent threats to public health and safety; for health oversight activities such as evaluations, investigations, audits, and inspections; to governmental agencies that monitor your services; for lawsuits and similar proceedings; for public health purposes such as to prevent the spread of a communicable disease; for certain approved research purposes; for law enforcement reasons if required by law or in regards to a crime or suspect; to correctional institutions in regards to inmates; to coroners, medical examiners and funeral directors (for decedents); as required by law (ordered subpoena or discovery requests); for organ and tissue donation; for specialized government functions such as military and veterans activities, national security and intelligence purposes, and protection of the President; for Workers’ Compensation purposes; for the management and coordination of public benefits programs; to respond to requests from the U.S. Department of Health and Human Services; and for us to receive assistance from consultants that have signed an agreement requiring them to maintain the confidentiality of your personal information. Also, if you have a guardian or a power of attorney, we are permitted to provide information to your guardian or attorney in fact. In many of these cases you will have advance notice of such release. Uses and Disclosures That Require Your Permission

We are prohibited from selling your personal information, such as to a company that wants your information in order to contact you about their services, without your written permission.

We are prohibited from using or disclosing your personal information for marketing purposes, such as to promote our services without your written permission.

All other uses and disclosures of your health information not described in this Notice will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the purposes state in your written permission except for those that we have already made prior to your revoking that permission.

Prohibited Uses and Disclosures

If we use or disclose your health information for underwriting purposes, we are prohibited from using and disclosing the genetic information in your health information for such purposes.


If any state or federal privacy laws require us to provide you with more privacy protections than those explained here, then we must also follow that law. For example, drug and alcohol treatment records generally receive greater protections under federal law.


You have the following rights regarding your health information:

  • Right to Inspect and Copy. You have the right to request access to certain health information we have about you. Fees may apply to copied information. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to WomenSafe Privacy Officer. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state for federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.*
  • Right to an Electronic Copy of Electronic Medical Records. If you Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable cost-based fee for the labor associated with transmitting the electronic medical record.
  • Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
  • Right to Amend. You have the right to request corrections or additions to certain health information we have about you. You must provide us with your reasons for requesting the change.*
  • Right to An Accounting of Disclosures. You have the right to request an accounting of the disclosures we make of your health information, except for those made with your permission and those related to treatment, payment, our health care operations, and certain other purposes. Your request must include a timeframe for the accounting, which must be within the six years prior to your request. The first accounting is free but a fee will apply if more than one request is made in a 12-month period.*
  • Right to Request Restrictions. You have the right to request that we restrict the information we use or disclose about you for purposes of treatment, payment, health care operations and informing individuals involved in your care about your care or payment for that care. We will consider all requests for restrictions carefully but are not required to agree to any requested restrictions.*
  • Right to Request Confidential Communications. You have the right to request that when we need to communicate with you, we do so in a certain way or at a certain location. For example, you can request that we only contact you by mail or at a certain phone number.
  • Right to a Paper Copy of Notice. You have the right to receive a paper copy of this Notice. This Notice is also available at our web site but you may obtain a paper copy by contacting the office at any time.

To exercise any of the rights described in this paragraph, please contact:

Privacy Officer, Andrea Gutka
12041 Ravenna Road
Chardon, OH 44024
(440) 286-7154 ext. 224

* To exercise rights marked with a star (*), your request must be made in writing. Please contact us if you need assistance.


We reserve the right to change this Notice at any time. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of our current Notice at our office and on our website at: In addition, each time there is a change to our Notice, you will receive information about the revised Notice and how you can obtain a copy of it. The effective date of each Notice is listed on the first page in the top center.


If you believe your privacy rights have been violated, you may file a complaint with the Board or with the Secretary of the Department of Health and Human Services. To file a complaint with WomenSafe, contact the Privacy Officer at the address above. You will not be penalized or retaliated against for filing a complaint.

If you wish to file a complaint with the Secretary you may send the complaint to:

Office for Civil Rights
U.S. Department of Health and Human Services
Attn: Regional Manager
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

WomenSafe may change the terms of this Notice at any time. If WomenSafe change this Notice, WomenSafe may make the new Notice terms effective for all of your PHI WomenSafe maintain, including any information WomenSafe created or received before we issued the new Notice. If WomenSafe change this Notice, WomenSafe will make it available to you.