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.
As a health care provider, Treatment Management Behavioral Health, (“Entity”) uses confidential personal health information about patients, referred to below as protected health information (“PHI”). Entity protects the privacy of this information, and it is also protected from disclosure by state and federal law. In certain specific circumstances, pursuant to this Notice of Privacy Practices (“Notice”), patient authorization or applicable laws and regulations, PHI can be used by Entity or disclosed to other parties. Below are categories describing these uses and disclosures, along with some examples to help you better understand each category..
Uses and Disclosures for Treatment, Payment and Health Care Operations. Entity may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining written authorization from you
For Treatment. Entity may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider. Information obtained by Entity will be used to furnish health care services, items and supplies to you. We will document in your record information related to the items dispensed to you and services provided to you.
For Payment. Entity may use and disclose PHI in order to bill and collect payment for the health care services provided to you. For example, Entity may contact your insurer or to determine whether it will pay for your health care or to determine the amount of your copayment. We will bill your health plan for health care items and services supplied to you, and we may bill you as well. The information on the bill may include information that identifies you, as well as items and services you are receiving.
For Health Care Operations. Entity may use and disclose PHI as part of its operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive and the performance of our staff in caring for you, provider training, compliance and risk management activities, planning and development, and management and administration. Entity may disclose PHI to attorneys, consultants, accountants, and others to help make sure Entity is complying with all applicable laws, and to help Entity continue to provide health care to its patients at a high level of quality.
Other Uses and Disclosures For Which Authorization is Not Required. In addition to using or disclosing PHI for treatment, payment and health care operations, Entity may use and disclose PHI without your written authorization under the following circumstances:
As Required by Law and Law Enforcement. Entity may use or disclose PHI when required to do so by applicable law. Entity also may disclose PHI when ordered to do so in a judicial or administrative proceeding, to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, the location of the crime or victims, or the identity, description, or location of a person who committed a crime, or for other law enforcement purposes.
For Public Health Activities and Public Health Risks. Entity may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence, reactions to medications or product defects or problems, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.
For Health Oversight Activities. Entity may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws.
Coroners, Medical Examiners, and Funeral Directors. Entity may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.
Organ, Eye, and Tissue Donation. Entity may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation.
Research. Under certain circumstances, Entity may use and disclose PHI for medical research purposes.
To Avoid a Serious Threat to Health or Safety. Entity may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.
Specialized Government Functions. Entity may use and disclose PHI of military personnel and veterans under certain circumstances. Entity may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations.
Workers’ Compensation. Entity may disclose PHI to comply with workers’ compensation or other similar laws. These programs provide benefits for work-related injuries or illnesses.
Prescription Refill/Appointment Reminders; Health-related Benefits and Services; Marketing. Entity may use and disclose your PHI to contact you and remind you of a prescription refill, or to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs. Entity may use and disclose your PHI to encourage you to purchase or use a product or service through a face-to-face communication or by giving you a promotional gift of nominal value.
Disclosures to You or for HIPAA Compliance Investigations. Entity may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Entity must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate Entity’s compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
Uses and Disclosures To Which You Have an Opportunity to Object. You will have the opportunity to object to these categories of uses and disclosures of PHI that Entity may make:
Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, Entity may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. Entity may also notify those people about your location or condition.
Other Uses and Disclosures of PHI For Which Authorization is Required. Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require authorization. Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations you have the right to revoke in writing.
Uses and Disclosures Subject to State and Other Laws. In addition to the federal privacy regulations that require this notice (called the “HIPAA” regulations), there are state and other federal health information privacy laws. These laws on occasion may require your specific written permission prior to disclosures of certain particularly sensitive information (such as mental health, drug/alcohol abuse, or HIV/AIDS information) in circumstances that the HIPAA regulations would permit disclosure without your permission. Entity is required to comply not only with the HIPAA regulations but also with any other applicable laws that impose stricter nondisclosure requirements. For example, the California Confidentiality of Medical Information Act limits the disclosure of patient medical information by providers, health plans and many businesses. Other California laws also provide enhanced protections that limit the disclosure of patient medical information by clinics and health facilities, HIV testing information and information about individuals detained voluntarily or involuntarily. California law also imposes requirements on businesses seeking medical information from individuals for direct marketing.
Regulatory Requirements. Entity is required by law to maintain the privacy of your PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, to abide by the terms described in this Notice and to notify affected individuals following a breach of unsecured PHI. Entity reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all of the PHI it maintains. Before Entity makes an important change to its privacy policies, it will promptly revise this Notice and post a new Notice on our Web site. You have the following rights regarding your PHI:
You may request that Entity restrict the use and disclosure of your PHI. Except as noted below, Entity is not required to agree to any restrictions you request, but if Entity does so it will be bound by the agreed restriction except in emergency situations. Entity is required to agree to a requested restriction for disclosures to a health plan for payment or health care operations purposes relating solely to an item or service that you have paid for out-of-pocket in full.
You have the right to request that communications of PHI to you from Entity be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be made in writing and sent to email@example.com. Entity will accommodate your reasonable requests without requiring you to provide a reason for your request.
Generally, you have the right to inspect and copy your PHI that Entity maintains, provided that you make your request in writing and sent to firstname.lastname@example.org. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), Entity will inform you of the extent to which your request has or has not been granted. In some cases, Entity may provide you a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you request copies of your PHI or agree to a summary of your PHI, Entity may impose a reasonable fee to cover copying, postage, and related costs. If Entity denies access to your PHI, it will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If Entity does not maintain the PHI you request, if it knows where that PHI is located it will tell you how to redirect your request.
If you believe that your PHI maintained by Entity contains an error or needs to be updated, you have the right to request that Entity correct or supplement your PHI. Your request must be made in writing and sent to email@example.com, and it must explain why you are requesting an amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Entity will inform you of the extent to which your request has or has not been granted. Entity generally can deny your request if your request relates to PHI: (i) not created by Entity; (ii) that is not part of the records Entity maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, Entity will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and Entity’s denial attached; and (iii) complain about the denial. You generally have the right to request and receive a list of the disclosures of your PHI Entity has made at any time during the six (6) years prior to the date of your request. The list will not include disclosures for which you have provided a written authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for Entity’s patient directory or to persons involved in your health care; (iv) for national security or intelligence purposes; or (v) to correctional institutions or law enforcement officials. You should submit any such request to firstname.lastname@example.org, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Entity will respond to your request. You have the right to receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.
You may complain to Entity if you believe your privacy rights with respect to your PHI have been violated by contacting email@example.com and submitting a written complaint. Entity will in no manner penalize you or retaliate against you for filing a complaint regarding Entity’s privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services.
If you have any questions about this notice, please contact firstname.lastname@example.org
Effective Date: January 1, 2017
I understand that in order to promote the safety of employees and company visitors, as well as the security of its facilities, Entity may conduct video surveillance of any portion of its premises at any time, the only exception being private areas of restrooms and showers, and that video cameras will be positioned in appropriate places within and around Entity buildings and used in order to help promote the safety and security of people and property. By my signature below I give my consent to such video surveillance at any time the company may choose.