NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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 questions about this notice, please contact Larry H. Turner, Privacy Official, at (317) 849-0599.
WHO WILL FOLLOW THIS NOTICE.
This notice describes the practices of Springtime Counseling Center (SCC) and that of: 1.) any health care professional authorized to enter information into your records; 2.) all departments, entities and affiliates of SCC; 3.) any member of a volunteer group we allow to help you at SCC; 4.) all employees and staff members. All entities, listed above follow the terms of this notice. In addition, these entities may share medical information about you with each other for treatment, payment or SCC operations purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION.
We treat all Protected Health Information (PHI) about you and your health as personal and confidential. We create a medical chart for you at SCC as we need this record in order to provide you with quality care and to comply with state regulations. This notice applies to all of the records of your care recorded at SCC. Other treatment centers may follow different policies or notices regarding use and disclosure of your medical information. This notice will tell you about the ways in which we may use and disclosure your PHI. We also describe your rights and certain obligations we have regarding the use and disclosure of your PHI. We are required to: 1.) make certain that medical information that identifies you is kept private; 2.) to give you notice of our legal duties and privacy practices with respect to medical information about you; and 3.) to follow the terms of the notice that is currently in effect.
HOW WE USE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed.
We may use medical information about you to provide you with medical treatment or services. We may share medical information about you among SCC's referral doctors, psychologists, nurses, social workers, therapists, technicians, approved practicum students, or other SCC associates who have been involved in taking care of you.
We may use and disclose medical information about you so that the treatment services you receive at SCC, or other health care providers from whom you receive treatment, may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need to give your health plan information about your treatment at SCC so your health plan will pay us or reimburse you for your treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the cost of such treatment.
For Health Care Operations.
We may use and disclose medical information about you for SCC operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan. These uses and disclosures are necessary to run SCC and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services SCC should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students, and other personnel for review and learning purposes. Should any information about you be used by SCC in conjunction with other health care providers for research or needs assessments, SCC will remove your name and all other identifying information.
We may use and disclose medical information to contact you, by phone or letter, as a reminder that you have an appointment for treatment or other services at SCC.
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services.
We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care.
Under certain limited circumstances, we may release limited information about you to a person or family member who is involved in your medical care. For example, a family member attending all or a portion of your treatment program who already is aware that you are a patient at SCC.
Under certain circumstances, we may use and disclose medical information about you with SCC staff or to a contracted business associate for research purposes. For example, a research project may involve comparing the health and recovery of patients who receive one medication to those who received another, having the same condition. If we provide information to a source outside of SCC, we may remove information that identifies you.
Organ and Tissue Donation.
If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplatation.
Military and Veterans.
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Coroners, Medical Examiners and Funeral Directors.
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of SCC to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities.
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary 1.) for the institution to provide you with health care; 2.) to protect your health and safety or the health and safety of others; or 3.) for the safety and security of the correctional institution.
WHEN WE ARE REQUIRED BY LAW TO DISCLOSE MEDICAL INFORMATION ABOUT YOU.
We will disclose medical information about you only by your authorization or when required to do so by federal, state or local law, including:
To Avert a Serious Threat to Health or Safety.
We will use and disclose medical information about you when we have a "Duty to Report" under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the heath and safety of the public or another person. Such disclosures would be limited to persons able to help prevent the threat.
Public Health Risks.
We will disclose medical information about you for public health reporting required by federal and state law, including, but not limited to: 1.) preventing or controlling disease, injury or disability; 2.) reporting abuse, neglect, or domestic violence; 3.) reporting reactions to medications or problems with products; or 4.) notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Health Oversight Activities.
Including, but not limited to audits, investigations, inspections, and licensure activities necessary for the government to monitor the health care system, government programs, and compliance with various laws.
Lawsuits and Legal Action.
If you are involved in a lawsuit or legal action, we will disclose medical information about you only with your authorization or by court order. Federal rules restrict substance abuse treatment information from being used to criminally investigate or prosecute any alcohol or drug abuse patient.
We will release medical information about you by your authorization or as required or permitted by law: 1.) in response to a court order; 2.) about the victim of a crime in certain limited circumstances; 3.) about criminal conduct at an SCC facility; and 4.) in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime; 5.) if you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information for the institution to provide you with health care or to protect your or other's health and safety.
We will disclose medical information about you: 1.) if you are a member of the armed forces and we are required to do so by military command authorities; 2.) to someone assisting in disaster relief so that your family can be notified about your status and location; 3.) to federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations; 4.) to coroners, medical examiners, and funeral directors as necessary for them to carry out their duties; and 5.) to authorized federal officials for intelligence, counterintelligence, and other national security activities when authorized by law.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy.
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing, but does not include psychotherapy notes. To inspect and receive copies of your medical chart, you must submit your request in writing to Larry H. Turner, Privacy Official. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances . If you are denied access to medical information, under some circumstances you may request that the denial be reviewed. The person conducting the review will not be the person who denied your initial request.
Right to Amend.
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for SCC. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: 1.) is already accurate and complete; 2.) was not created by SCC, unless the person or entity that created the information is no longer available to make the amendment; 3.) is not part of the medical record kept by or for SCC; or 4.) is not part of the information which you would be permitted to inspect and copy.
Right to an Accounting of Disclosure.
You have the right to request an "Accounting of Disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to Larry H. Turner, Privacy Official. Your request must state a time period which may not be longer than six years and may not include dates before April 3, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will attempt to notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a specific treatment session you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Larry H. Turner, Privacy Official. In your request, you must tell us 1.) what information you want to limit; 2.) whether you want to limit our use, disclosure or both; and 3.) to whom you want the limits to apply, for example, disclosure to your spouse.
Right to Request Confidential Communications.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you electronically, at work, or by mail. To request confidential communications, you must make your request in writing to Larry H. Turner, Privacy Official. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice from any employee at the SCC outpatient office. You may also obtain a copy of this notice at our website, www.MyDuiGuy.com .
CHANGES TO THIS NOTICE.
We reserve the right to change this notice. We reserve the right 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 a copy of the current notice in out outpatient facility. The notice will contain on the first page, in the top right-hand-corner, the effective date. In addition, each time you register at or are admitted to SCC for treatment or health care services as an outpatient, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with SCC or with the Secretary of the Department of Health and Human Services. To file a complaint with SCC, contact
Larry H. Turner, director, 6515 E. 82 nd Street, Suite 102, Indianapolis, IN 46250, (317) 849-0599. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Complaints submitted to the Secretary of the Department of Health and Human Services should be addressed as follows:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical 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 permission to use or disclose medical 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 medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you according the above provisions.
ACKNOWLEDGEMENT OF RECEIVING THE PRIVACY NOTICE AND THE NOTICE OF PRIVACY PRACTICES
I have read the above Privacy Notice regarding federal rules 42 CFR Part 2 and also the Notice of Privacy Practices regarding the federal HIPAA rules and I signify my approval or disapproval of their content as signified by the following indicator: