Your Information – Your Rights – Our Responsibilities
Please review this notice carefully
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Amy Charley, Compliance Officer, 100 SE Third Ave, Suite 1800 Ft Lauderdale 33394; by phone at: 754-300-3120 ext. 4019; or by email at email@example.com.
Your Health Information
As per 45 CFR 164.520, this Notice of Privacy Practices (the Notice) describes how medical information about you may be used or disclosed and how you can access this information. Your personal health record contains private and confidential information about you and your health. Both State and Federal laws protect the confidentiality of this information. Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes any individually identifiable health information. PHI relates to your past, present or future physical or mental health or condition and any related health care services.
Below are examples of the uses and disclosures that we may make of your Protected Health Information (PHI). These examples are not exhaustive but simply describe the uses and disclosures that may be made.
Treatment – Your PHI may be used and disclosed by your physician, counselor, our program staff and others outside of our program that are involved in your care for the purpose of providing, coordinating or managing your health care treatment and any related services. Example: Your care while with us may require coordination or management from a third party, consultation with other health care providers, or referral to another provider for health care treatment. Additionally, we may disclose your protected health information to another physician or health care provider who becomes involved in your care.
Payment – With your authorization, we may use and disclose PHI about you so that we can receive payment for the treatment and services provided to you from your insurance or other payor sources. Example: We give information about you to your health insurance so it will pay for your services.
Healthcare Operations – We may use and share your health info to run our business, improve your care, and contact you when necessary. This may include quality assessment activities, employee review activities, licensing, and conducting other business activities. Examples: using a sign-in sheet where you will be asked to sign your name and indicate your physician, counselor or staff. We may share your PHI with third parties that perform various business activities for us, such as a billing company. Also, we may contact you by phone to remind you of your appointments or to provide you with additional information regarding your treatment or other health-related benefits.
Special Rules Regarding Disclosure of Behavioral Health, Substance Abuse, and HIV- Related Information:
For disclosures concerning protected health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply.
Other Uses and Disclosures That Do Not Require Your Authorization
Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.
Public Health. We may use or disclose your PHI for public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority. In certain circumstances outlined in the Privacy Regulations, we may disclose your PHI to a person who is subject to the jurisdiction of the Food and Drug Administration with respect to the reporting of certain occurrences involving food, drugs, or other products distributed by such person. In certain limited circumstances, we may also disclose your PHI to a person that may have been exposed to a communicable disease or may otherwise be at risk of spreading or contracting such disease, if such disclosure is authorized by law. For example, we may disclose PHI regarding the fact that you have contracted a certain communicable disease to a public health authority authorized by law to collect or receive such information.
Medical Emergencies. We may use or disclose your protected health information in a medical emergency situation to medical personnel only. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the initial mandated report.
Deceased Patients. We may disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations; and (d) the researchers agree not to re-disclose your protected health information except back to the company.
Criminal Activity on Program Premises/Against Program Personnel. We may disclose your PHI to law enforcement officials if you have committed a crime on program premises or against program personnel or its agents.
Court Order. We may disclose your PHI if a court of competent jurisdiction issues an appropriate court order and the disclosure of PHI is explicitly permitted under Federal and State law.
Interagency Disclosures. Limited PHI may be disclosed for the purpose of coordinating services among government programs that provide mental health services where those programs have entered into an interagency agreement.
Public Safety. If you are in a mental health treatment program only, we may disclose PHI to avert a serious threat to health or safety, such as physical or mental injury being inflicted on you or someone else.
Specialized Government Functions. If you are or have been a member of the U.S. Armed Forces, we may disclose your PHI as required by military command authorities. We may disclose your PHI to authorized federal officials for national security and intelligence reasons and to the Department of State for medical suitability determinations.
Family and Friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into treatment center or while treatment is discussed. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care.
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization at any time, unless the program or its staff has taken an action in reliance on the authorization of the use or disclosure you permitted. If you revoke it, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization, unless required to do so by law. You should understand that we are unable to take back any disclosures we have already made with your authorization and that we are required to retain our records of the treatment and care that we have provided to you.
Your rights with respect to your protected health information are explained below. Any requests with respect to these rights must be in writing and made to the attention of the Privacy Officer. A brief description of how you may exercise these rights is included:
You have the right to inspect and copy your PHI – You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the record. A “designated record set” contains medical and billing records and any other records that the program uses for making decisions about you. Your request must be in writing. We may charge you a reasonable cost-based fee for the copies. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right to appeal the denial of access.
You may have the right to amend your PHI – You may request, in writing, that we amend your PHI that has been included in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of it.
You have the right to receive an accounting of some types of PHI disclosures. You may request an accounting of disclosures for a period of up to six years, excluding disclosures made to you, made for treatment purposes or made as a result of your authorization. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
You have a right to receive a paper copy of this notice. You have the right to obtain a copy of this notice from us whether by paper or via email.
You have the right to request added restrictions on disclosures and uses of your PHI – You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions.
You have a right to request confidential communications. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable, written requests. We may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. We will not ask you why you are making the request.
You have a right to receive notification of unauthorized disclosure of your PHI (Breach Notification). We are required to notify you upon a breach of any unsecured PHI. The notice must be made without unreasonable delay, but no later than 60 days from when we discover the breach.
Changes to This Notice
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post the current notice at our location(s) with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
You may file a complaint if you feel your rights are violated.
Changes to the Terms of this Notice – We may change the terms of this notice and the changes will apply to all the private health information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.