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PRIVACY
NOTICE This notice describes how CMH
Services of may use and disclose personal and
medical information about you that we have collected. It also explains how you can get
access to this information. This Privacy Notice is effective April
14, 2003 |
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PROTECTED HEALTH INFORMATION In order to provide services to you,
we need to collect private information from you. The private information that we collect
from you is known as Protected Health
Information under the HIPAA regulations. “Protected Health Information”
(referred to as “private information” in the remainder of this Notice) is: · Information
about you that may identify you and · relates
to your past, present or future physical or mental health
condition, and · health care services
related to your health or condition. ROUTINE DISCLOSURES: [WAYS THAT
WE MAY USE AND DISCLOSE YOUR PRIVATE INFORMATION] The following section of this Notice
explains the ways in which we may routinely use and disclose your private
information. “Use and disclose” will be referred
to as “share” in the remainder of this Notice. There are
times that we will need to share your private information with other people
and/or entities. We may do so in
instances necessary for: (1)
treatment, (2) payment, (3)
and healthcare operations Treatment We may share
private information about you in the course of treatment. For instance, we may share your private
information with another provider to coordinate your services. Examples
of the private information that we may have to share with regard to
your treatment include: · Your
diagnosis (the condition for which you are receiving treatment). · Your
treatment plan and goals. · Your
progress toward those goals. Payment We
may share private information about you so the services that you receive can
be billed and paid for correctly.
Examples of the private information that we may have to share with
regard to payment for treatment include: · Your
name, address, telephone number, and date of birth. · Your
insurance information (including medication authorizations). · Your
diagnosis (the condition for which you are receiving treatment). · The
date(s) that you received treatment. Healthcare
Operations We may share
private information about you in order
to carry out our business operations. Examples when we may have to share your
private information with regard to our daily business operations include: · Reviewing
the quality of services that you are receiving. · Maintaining
your clinical record. · Reminding
you of a scheduled appointment. · Fulfilling
a contract/licensure requirement. DISCLOSURES WHICH REQUIRE AN
AUTHORIZATION: [OTHER WAYS
THAT WE MAY SHARE YOUR PRIVATE
INFORMATION] The following section of this Notice
explains the ways in which we may share your private information with your
prior authorization. There are
times that we will need to share additional private information with other
people and/or entities. We will then
ask you to sign an authorization allowing us to do so. We may do so in instances necessary for: · Coordination with
another agency (such as a School, Nursing Home, or Family Independence
Agency). · Communication with an
individual involved in your care (such as a family member or a friend). · Collaboration with
another professional (such as your Primary Medical Doctor). MANDATORY DISCLOSURES: [OTHER WAYS
THAT WE MAY SHARE YOUR PRIVATE
INFORMATION] The following section of this Notice
explains the ways in which we may share your private information as required
by law. We may
share private information about you when we are required by law to do
so. We may do so for the following
reasons: · Law Enforcement Purposes (such as subpoenas or court
orders). · Public Health Risks (such as
communicable diseases). · To Avert a Serious Threat to Health
or Safety (such as harm to yourself or someone else, suspected
abuse of children or adults). · Other emergencies (such as
disaster relief or security threats). YOUR
PRIVACY RIGHTS You have
the following rights regarding the private information that we have about
you. Your requests must be made in
writing to the Privacy Officer. We may
charge you a fee to copy information from your record. Right to Inspect and Copy In most cases you have the right
to look at and receive a copy of information in your record. Right
to Amend If you think
that any of the information that we have about you is incorrect, you have the
right to request a change. If your
request is denied we will notify you in writing why your request was denied. Right
to Disclosure List You
have the right to request a list of disclosures made (by us) after April 14,
2003. This list will not include the
private information that we shared for treatment, payment, or healthcare
operations. The list will also not
include information provided directly to you or your family, or information
that was shared with your written permission. Right
to Request Restrictions
You
have the right to ask for limits on how we share your private
information. We are not required to agree with your request. Right
to Request Confidential
Communications You
have the right to request that we share information with you in a specific
way or a specific place. For example,
you can request that we call you at your work instead of at your home. QUESTIONS If you have
a question regarding this privacy notice or a request regarding your privacy
rights, you may contact: Privacy
Officer CMH
Services of 677 E Phone: 269-467-1000 Email: privacyofficer@stjoecmh.org COMPLAINTS If you feel
that your privacy rights have been violated, you may file a complaint with us
at: Privacy
Officer CMH
Services of 677 E. Phone: 269-467-1000 Email: privacyofficer@stjoecmh.org You may
also file a complaint with the Federal Government at: Secretary
of Health and Human Services Phone:
866-927-7748
TTY:
886-788-4989
Email:
ocrprivacy@hhs.gov YOU WILL
NOT BE PENALIZED FOR FILING A COMPLAINT CHANGES TO THIS PRIVACY
NOTICE We
may make changes to this notice in the future. If the changes are material, a new notice
will be available to you before your next service. You have the right to receive an additional copy of this notice at any time. |
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