Privacy Notice

PRIVACY NOTICE

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.

Chilton Shelby Mental Health Center (CSMHC) is required under the federal health care privacy rules (the "Privacy Rules"), to protect the privacy of your health information, which includes information about your health history, symptoms, test results, diagnoses, treatment, and claims and payment history (collectively, "Health Information").  CSMHC is also required to provide you with this Privacy Notice regarding CSMHC’s legal duties, policies and procedures to protect and maintain the privacy of your Health Information. CSMHC is required to follow the terms of this Privacy Notice unless (and until) it is revised.  CSMHC reserves the right to change the terms of this Privacy Notice and to make the new notice provisions effective for the Health Information that CSMHC maintains and uses, as well as for any Health Information that we may receive in the future.  Should the terms of this Privacy Notice change, CSMHC will promptly distribute a revised copy of the notice to you.  Revised Privacy Notices will be available at each office for individuals to take with them and a copy of revised Privacy Notices will be posted in a prominent location in each office.

Permitted Uses and Disclosures of Your Health Information.

  1. General Uses and Disclosures Which Require Consumer Consent. Under the Privacy Rules, CSMHC is permitted to use and disclose your health information, without obtaining your permission and authorization for the following purposes:

  • Treatment.  CSMHC is permitted to use and disclose your Health Information in the provision and coordination of your health care. For example, CSMHC may disclose your Health Information to other Chilton Shelby Mental Health Center employees who have a need for such information for your care and treatment.
  • Payment CSMHC is permitted to use and disclose your Health Information for the purposes of determining coverage, billing, and reimbursement. This information may be released to an insurance company, third party payor, or other authorized entity or person involved in the payment of your medical bills and may include copies or portions of your medical record which are necessary for payment of your bill. For example, a bill sent to your insurance company may include information that identifies you, your diagnosis, and the procedures and supplies used in your treatment.

  • Health Care Operations.  CSMHC is permitted to use and disclose your Health Information during CSMHC health care operations, including, but not limited to: quality assurance, auditing, licensing or credentialing activities, and for educational purposes.  For example, CSMHC can use your Health Information to internally assess CSMHC’s quality of care provided to consumers.

  1. Uses and Disclosures Which Require Consumer Opportunity to Verbally Agree or Object  Under the Privacy Rules, CSMHC is permitted to use and disclose your Health Information: (i) to disaster relief agencies, and (ii) to family members, close personal friends or any other person identified by you, if the information is directly relevant to that person's involvement in your care or treatment.  Except in emergency situations, you will be notified in advance and have the opportunity to verbally agree or object to this use and disclosure of your Health Information.

  2. Uses and Disclosures Which Require Written Authorization.  As required by the Privacy Rules, all other uses and disclosures of your Health Information (not described above) will be made only with your written Authorization.  For example, in order to disclose your Health Information to your primary health care provider, consulting providers and to other health care providers, CSMHC must obtain your Authorization. Under the Privacy Rules, you may revoke your Authorization at any time. The revocation of your Authorization will be effective immediately, except to the extent that:  CSMHC has relied upon it previously for the use and disclosure of your Health Information; if the Authorization was obtained as a condition of obtaining insurance coverage where other law provides the insurer with the right to contest a claim under the policy or the policy itself; or where your Health Information was obtained as part of a research study and is necessary to maintain the integrity of the study.

  3. Uses and Disclosures Which Do Not Require Consent, Authorization or Opportunity to Verbally Agree or Object.  Under the Privacy Rules, CSMHC is permitted to use or disclose your Health Information without your Consent, Authorization or Opportunity to Verbally Agree or Object with regard to the following:

  • Uses and Disclosures Required by Law.  CSMHC may use and disclose your Health Information when required to do so by law, including, but not limited to:  reporting abuse, neglect and domestic violence; in response to judicial and administrative proceedings; or in order to alert law enforcement to criminal conduct on our premises or of a death that may be the result of criminal conduct.

  • Public Health ActivitiesCSMHC may disclose your Health Information for public health reporting, including, but not limited to: child abuse and neglect;  reporting communicable diseases and vital statistics; product recalls and adverse events; or notifying person(s) who may have been exposed to a disease or are at risk of contracting or spreading a disease or condition.

  • Abuse and Neglect. CSMHC may disclose your Health Information to a local, state, or federal government authority, if CSMHC has a reasonable belief of abuse, neglect or domestic violence.

  • Regulatory AgenciesCSMHC may disclose your Health Information to a health care oversight agency for activities authorized by law, including, but not limited to, licensure, investigations and inspections.  These activities are necessary for the government and certain private health oversight agencies to monitor the health care system, government programs, and compliance with civil rights.

  • Judicial and Administrative ProceedingsCSMHC may disclose your Health Information in judicial and administrative proceedings, as well as in response to an order of a court, administrative tribunal, or warrant.

  • Law Enforcement PurposesCSMHC may disclose your Health Information to law enforcement officials when required to do so by law.

  • Coroners, Medical Examiners, Funeral DirectorsCSMHC may disclose your Health Information to a coroner or medical examiner.  This may be necessary, for example, to determine a cause of death. CSMHC may also disclose your health information to funeral directors, as necessary, to carry out their duties.

  • Research.  Under certain circumstances, CSMHC may disclose your Health Information to researchers when their clinical research study has been approved and where certain safeguards are in place to ensure the privacy and protection of your Health Information.

  • Threats to Health and SafetyCSMHC may use or disclose your Health Information if CSMHC believes, in good faith, that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public, or is necessary for law enforcement to identify or apprehend an individual.

  • Specialized Government FunctionsCSMHC may disclose your Health Information to authorized federal officials for national security reasons.

  • Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, CSMHC may release your Health Information to the correctional institution or law enforcement official, where such information is necessary for the institution to provide you with health care; to protect your health or safety, or the health or safety of others; or for the safety and security of the correctional institution.

  • Workers' CompensationCSMHC may disclose your Health Information to your employer to the extent necessary to comply with Alabama laws relating to workers' compensation or other similar programs.

  • Appointment Reminders/Treatment Alternatives. CSMHC may use and disclose your Health Information to remind you of an appointment for treatment and medical care at our office or to provide you with information regarding treatment alternatives or other health-related benefits and services that may be of interest to you.

  • Business Associates. CSMHC may disclose your Health Information to business associates who provide services to CSMHC.  CSMHC’s business associates are required to protect the confidentiality of your Health Information.

  • Other Uses and Disclosures.  In addition to the reasons outlined above, CSMHC may use and disclose your Health Information for other purposes permitted by the Privacy Rules.

Consumer  Rights

You have the following rights concerning your Health Information:

  1. Right to Inspect and Copy Your Health Information.  Upon written request, you have the right to inspect and copy your own Health Information contained in a designated record set, maintained by CSMHC.  A "designated record set" contains medical and billing records and any other records that CSMHC uses for making decisions about you.  However, CSMHC is not required to provide you access to all the Health Information that we maintain.  For example, this right of access does not extend to certain psychotherapy notes, or information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative proceeding. Where permitted by the Privacy Rules, you may request that certain denials to inspect and copy your Health Information be reviewed.  If you request a copy or summary of explanation of your Health Information, CSMHC will charge you a reasonable fee for copying costs, including the cost of supplies and labor, postage, and any other associated costs in preparing the summary or explanation.

  2. Right to Request Restrictions on the Use and Disclosure of Your Health Information.  You have the right to request restrictions on the use and disclosure of your Health Information for treatment, payment and health care operations, as well as disclosures to persons involved in your care or payment for your care, such as family members or close friends. CSMHC will consider, but do not have to agree to, such requests.  However, some requests for restrictions regarding payment for your care, may result in termination of your services from Chilton Shelby Mental Health Center.

  3. Right to Request an Amendment of Your Health Information.  You have the right to request an amendment of your Health Information. CSMHC may deny your request if CSMHC determines that you have asked us to amend information that:  was not created by us, unless the person or entity that created the information is no longer available; is not Health Information maintained by or for CSMHC; is Health Information that you are not permitted to inspect or copy; or CSMHC determines that the information is accurate and complete.  If CSMHC disagrees with your requested amendment, CSMHC will provide you with a written explanation of the reasons for the denial, an opportunity to submit a statement of disagreement, and a description of how you may file a complaint.

  4. Right to an Accounting of Disclosures of Your Health Information.  You have the right to receive an accounting of disclosures of your Health Information made by CSMHC within six (6) years prior to the date of your request.  The accounting will not include:  disclosures related to treatment, payment or health care operations; disclosures to you; disclosures based on your Authorization; disclosures that are part of a Limited Data Set; incidental disclosures; disclosures to persons involved in your care or payment for your care; disclosures to correctional institutions or law enforcement officials; disclosures for facility directories; or disclosures that occurred prior to April 14, 2003.

  5. Right to Alternative Communications.  You have the right to receive confidential communications of your Health Information by a different means or at a different location than currently provided.  For example, you may request that CSMHC only contact you at home or by mail.

  6. Right to Receive a Paper Copy of this Privacy Notice.  You have the right to receive a paper copy of this Privacy Notice upon request, even if you have agreed to receive this Privacy Notice electronically.

If you want to exercise any of these rights, please contact our Privacy Officer.  All requests must be submitted to us in writing on a designated form (which CSMHC will provide to you), and returned to the attention of our Privacy Officer at the address below.

Contact Information and How to 
Report a Privacy Rights Violation

If you have questions and/or would like additional information regarding the uses and disclosures of your Health Information, you may contact our Privacy Officer at:

Address: P.O Drawer 689
Calera, AL 35040
Attn: Ms. Kathryn Crouthers, COO
Telephone: 205-668-4308
Fax:   205-668-4957

If you believe that your privacy rights have been violated or that CSMHC has violated the agency’s privacy practices, you may file a complaint with CSMHC. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201.  Complaints filed directly with the Secretary must be made in writing, name CSMHC, describe the acts or omissions in violation of the Privacy Rules or the agency’s privacy practices, and must be filed within 180 days of the time you knew or should have known of the violation.  Complaints submitted directly to CSMHC must be in writing and to the attention of our Privacy Officer.  There will be no retaliation for filing a complaint.

The Effective Date of this Privacy Notice is October 17, 2006.