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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.
-
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.
-
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.
-
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.
-
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 Activities.
CSMHC 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
Agencies. CSMHC
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 Proceedings.
CSMHC 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 Purposes.
CSMHC may
disclose your Health Information to law enforcement officials when
required to do so by law.
-
Coroners,
Medical Examiners, Funeral Directors.
CSMHC 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 Safety.
CSMHC 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 Functions.
CSMHC 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'
Compensation. CSMHC
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:
-
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.
-
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.
-
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.
-
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.
-
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.
-
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: |
205-668-1327 |
| Fax: |
205-668-2443 |
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. |
