Community Mental Health & Substance Abuse Services of St. Joseph County

Privacy Notice

This notice describes how Community Mental Health & Substance Abuse Services of St. Joseph County 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:

1. Information about you that may identify you
2. To your past, present or future physical or mental health condition, and
3. Health care services related to your health or condition

ROUTINE DISCLOUSURES

[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 dislose] will be refered as [Share] in the reminder 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. Health care 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:

1. Your diagnosis (the condition for which you are receiving treatment).
2. Your treatment plan and goals.
3. Your progress towards 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:

1. Your name, address, telephone number, and date of birth.
2. Your insurance information (including medication authorizations).
3. Your diagnosis (the condition for which you are receiving treatment).
4. 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 operations include:

1. Reviweing the quality of services that you are receiving.
2. Maintaining your clinical record.
3. Reminding you of a scheduled appointment.
4. Fulfulling a contract/licensure requirement.

DISCLOUSURES THAT 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:

1. Coordination With another agency (such as a School, Nursing Home or Family Independence Agancy).
2. Coordination With an individual involved in your care (such as a family member or a friend).
3. Collaboration With another professional (such as your Primry Medical Doctor).

MANDATORY DISCLOUSURES

[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:

1. Law Enforcement Purposes (such as subpoenas or court orders).
2. Public Health Risks (such as communicable diseases).
3. To Avert a Serious Threath to Health or Safety (such as harm to yourself or someone else, suspected abuse of children or adults).

YOUR PRIVACY RIGHTS

You have the following rights regarding the private information what 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 your information in your record.
• Right to Amend If you think 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 place. For example, you can request that we call you at your works 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 of St Joseph County.
• 677 E Main Street, Suite A Centreville, MI 49032
• Phone: 269-467-1000.
• 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 of St Joseph County.
• 677 E Main Street, Suite A Centreville, MI 49032
• Phone: 269-467-1000.
• 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.