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Notice of Privacy Practices

Sage Health Services of Indiana, Inc./Fourth Street Solutions, L.L.C.
Effective August 1, 2014

In compliance with certain applicable laws, the Gramm-Leach-Bliley Act (GLBA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Sage Health Services of Indiana, Inc. (“Sage”)/Fourth Street Solutions, L.L.C. (Fourth Street) acknowledges clients’ privacy rights as specified in these laws, and has adopted policies and procedures to ensure your privacy rights are protected.

This Notice describes how Nonpublic Personal Financial Information (NPFI) and Protected Health Information (PHI) about you may be used and disclosed and how you can access this information. In this Notice, we explain how we protect the privacy of your NPFI and PHI, and how we will allow it to be used and given out (“disclosed”). We are required to provide you with a copy of this Notice of Privacy Practices upon request. We must follow the privacy practices described in this Notice while it is in effect.

Our Commitment Regarding Your Confidential Information:

We understand the importance of your Nonpublic Personal Financial Information (NPFI) and Protected Health Information (PHI), hereafter known as “confidential information,” and follow strict policies (in accordance with state and federal privacy laws) to keep your information private.

Our Privacy Principles:

Confidential Information Collected:

Information Disclosed:

Security of Your Confidential Information:

Individual Rights:

Duties:

Further information:

If you need more information about our privacy policy, or are concerned that we may have violated your privacy rights, please contact:

Privacy Officer
Sage Health Services of Indiana, Inc./Fourth Street Solutions, L.L.C.
215 S.E. Fourth Street
Evansville, IN  47713

You may also submit a written complaint to:

Region V, Office of Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
Voice Mail: (312) 866-2359
Fax: (312) 866-1807

We support your right to protect the privacy of your confidential information. We will not take action against you if you file a complaint with us or with the U.S. Department of Health and Human Services.