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PRIVACY
NOTICE This
notice describes how CMH Services of St. Joseph County
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. PLEASE
REVIEW IT CAREFULLY
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.
If
you have a question regarding this privacy notice or a request regarding
your privacy rights, you may contact: Privacy
Officer
CMH
Services of St. Joseph County
210
S. Main Street
Three
Rivers, MI 49093
Phone:
269-273-5000
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 St. Joseph County
210
S. Main Street
Three
Rivers, MI 49093
Phone:
269-273-5000
Email:
privacyofficer@stjoecmh.org You
may also file a complaint with the Federal Government at: Secretary
of Health and Human Services
200
Independence Avenue, SW
Washington,
DC 20201
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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