This notice describes how Protected Health Information about you may be used and disclosed, and how you can get access to this information.
Please review this information carefully.
This notice is effective April 14, 2003 and meets all requirements of HIP AA (Health Insurance Portability and Accountability Act).
- How WE WILL USE AND DISCLOSE CLINICAL INFORMATION ABOUT YOU WITH AN APPROPRIATE, SIGNED RELEASE OF INFORMATION.
- FOR TREATMENT: We may use clinical information about you to provide you with clinical treatment or services. We may disclose clinical information about you to doctors, therapists, case workers or other authorized personnel involved in your care. For example, your doctor may need to tell your therapist if a prescribed medication requires a certain amount of time to take effect. We may share information with outside people who are responsible for services related to those you receive here.
- FOR PAYMENT: We may use and disclose clinical information about you so that treatment and services you receive at our agency can be billed to you and payment may be collected from you, an insurance company or a third party payer. For example, we may need to inform your health plan about treatment you are going to receive in order to obtain prior approval and ensure that your treatment will be covered. We may need to share information with your insurance company about your treatment plan so your health plan will pay us or reimburse you.
OTHER USES OF YOUR CLINICAL INFORMATION: Other uses and disclosures of clinical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with written permission to use or disclose clinical information about you, you may revoke that permission in writing at any time. If you choose to revoke permission, we will no longer use or disclose clinical information about you for the reasons covered in your written authorization. Any disclosures made with your consent prior to this revocation cannot be withdrawn. Our agency is required to retain all records of the care we have provided you.
- YOUR RIGHTS CONCERNING PRIVACY OF YOUR CLINICAL INFORMATION
- You HAVE THE RIGHT TO INSPECT AND RECEIVE A COPY OF YOUR CLINICAL INFORMATION INCLUDING CLINICAL AND BILLING RECORDS: All requests to inspect or obtain a copy of your clinical information that may be used to make decisions about you must be submitted in writing. If you request a copy, we my charge a fee to cover the cost of copying , mailing or other supplies necessary to fulfill your request.
- You HAVE THE RIGHT TO REQUEST TO AMEND CLINICAL INFORMATION YOU FEEL IS INCORRECT OR INCOMPLETE: You may request an amendment for as long as we keep the information. Your request, including a reason to support the request, must be made in writing. Your request may be denied for any of the following reasons. (1) Request was not made in writing and did not include a reason. (2) The information was not created by our agency. If the creator of the information is no longer available to make the amendment, we will fulfill the request. (3) It is not part of the information retained by our agency. (4) It is not part of the information you are permitted to inspect. (5) The information is accurate and complete.
- YOU HAVE THE RIGHT TO REQUEST TO AMEND CLINICAL INFORMATION YOU FEEL IS INCORRECT OR INCOMPLETE: Your request must state a time period no longer than six
years and cannot include any dates prior to April 14, 2003. The first list that you request within a twelve month period will be free. We may charge for the costs of providing additional lists. We will notify you of the costs involved at which time you may choose to withdraw, modify or keep your original request without any cost incurred. Your request must be made in writing.
- FOR HEALTH CARE OPERATIONS: We may use and disclose your Protected Health Information (PHI) for internal purposes regarding your care for the purpose of:
- Acquiring additional recommended treatment possibilities from other clinicians.
- Combining your information within our office to acquire additional changes.
- We may use information for learning purposes.
- Evaluating the performance of our staff in providing services to you.
- We may use this information for appointment reminders.
- Providing you with treatment alternatives.
We may disclose your PHI externally, with appropriate releases, for the purpose of:
- Releasing information to your insurance company, care giver, or an individual who assists in paying for your care.
- Releasing information to disaster relief personnel to locate you or your family if necessary.
- Combining information from our center with other centers for quality review, to evaluate other services offered or for research. We may remove any identifying information about you prior to this exchange or seek specific permission if researchers have access to information that would identify you. Our agency will disclose information about you when required by federal, state or local law.
- OTHER USES AND DISCLOSURES ALLOWED WITHOUT YOUR AUTHORIZATION: Our agency may release information about you without authorization for the following reasons:
- For public health activities. This may include: (1) reporting child or adult neglect, (2) Notifying individuals of product recalls, (3) Notifying authorities of a victim of abuse, neglect or domestic violence when authorized by the patient or required by law, (4) Preventing and/or controlling disease.
- Limited information may be released for your Employee Assistance Program (EAP) or county Central Point of Coordination (CPC) or similar programs that provide benefits for you.
- To a health oversight agency as authorized by law.
- You are involved in a lawsuit – in response to a court or administrative order, or in response to a subpoena, delivery request, or other lawful process by another party in the dispute. Efforts will be made to tell you about the request.
- To a coroner or medical examiner.
- To authorized federal officials in service to protect the President or other heads of state, or to conduct special investigations.
- To the institution or official if you are an inmate of a correctional institution or under custody of law enforcement officials.
- To a law enforcement official in response to a court subpoena, warrant, summons or other lawful process; to identify a suspect, fugitive, witness or missing person; about a victim; criminal conduct or criminal death; or in emergency circumstances concerning crime information.
- If you are a member of the armed forces as required by military command authorities.
- YOUR RIGHTS CONCERNING PRIVACY OF YOUR PROTECTED HEALTH INFORMATION:
Individuals seeking treatment have the right to request that we restrict our uses and disclosures of the Protected Health Information (PHI). We are not obligated to agree to those restrictions. Ifwe do, however, we must abide by them. Therefore, restrictions to consents will not be granted without the express permission of the Executive Director who will evaluate an individual’s request to determine if the restrictions are reasonable and if it is possible to implement the restriction in our practice. Should the request be granted, the consent form will reflect the restrictions that have been allowed. Your request must tell us what information you want to limit and whether you want to limit use of disclosure or both, and who you want the limits to apply to. Your request must be made in writing.
You have a right to a paper copy of this notice. You may ask us for a copy of this notice at any time. You may obtain a copy of this notice at the front desk. There will be a copy of this notice posted at our office. All requests that are required in writing must be sent to:
Crossroads Behavioral Health Services Privacy Officer
1003 Cottonwood Road
Creston, Iowa 50801
This Privacy Notice may change at the will of the Executive Director and the Board of Directors. Any changes would affect all existing PHI. You have the right to a copy of any new revisions should they occur. A copy of the current notice is posted in a public place at our agency. You will be offered a copy of the Privacy Notice when you become a client or at a scheduled visit for existing clients.
If you believe your privacy rights have been violated, you may file a complaint with our agency or with the Secretary of the Department of Health and Human Services. Complaints filed with this agency must be submitted in written form and mailed to:
Privacy Officer Crossroads Behavioral Health Services
1003 Cottonwood Road
Creston, Iowa 50801
There is no penalty for filing a complaint.