FOUR RIVERS BEHAVIORAL HEALTH
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.
Our Duty To Safeguard Your Protected Health Information:
We understand that information about you and your treatment is personal. We are committed to protecting information about you. We create a record of the care and services you receive from this agency. We need this record in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care/treatment/service generated by this agency.
We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice in the lobby. You may request a copy of the new notice from the secretary at the front desk.
How We May Use And Disclose Your Protected Health Information:
The following categories describe different ways that we typically use and disclose protected health information (PHI). For each category of uses or disclosures we will explain what we mean and try to give some examples. You have the right to request restrictions on our uses and disclosures. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
· For Treatment: We may use the protected health information about you to provide you with treatment and services. We may disclose information about you to doctors, nurses, or others who are involved in your care (such as spouse, significant other family member). For example, your information will be shared among members of your treatment team, or with our staff psychiatrist. During the intake process, you will be given the opportunity to designate who you want to involved and be aware of your treatment. We may then contact this person in order to make or change and appointment for you. Your information may be shared with outside agencies performing ancillary services relating to your treatment, such as lab work or drug screens.
· For Payment: We may use and disclose protected health information about you so that treatment and services you receive at the agency may be billed to and payment collected from you, and/ or a third party(i.e. Insurance, Medicare, Medicaid, or State). For example, we may release portions of your protected health information to the Medicaid program and/or a private insurer to get paid for services that we delivered to you. During the intake process, you will be given the opportunity to designate who you want to be the Responsible Party regarding payment issues.
· For Health Care Operations: We may use and disclose protected health information about you in the course of operating our behavioral health agency. For example, we may use your information in evaluating the quality of services provided, or disclose your information to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your information to designated staff for similar purposes. Release of your information to state agencies might also be necessary to determine your eligibility for publicly funded services.
Four Rivers Behavioral Health has reciprocal agreements with the agencies listed below and your protected health information may be discussed or released to them only on a need to know basis.
1. Western State Hospital
2. Murray/Calloway Co. W.A.T.C.H. (MR/DD)
3. Marshall Co. Exceptional Center (MR/DD)
4. J. U. Kevil Memorial Foundation (MR/DD)
5. West Kentucky Easter Seals Center (MR/DD)
6. Community Alternatives of KY (MR/DD)
7. Department of Medicaid/Medicare/Insurance or any other third party payor.
8. Department of MH/MR services.
9. DUI Programs (Behavior Management Inc., W. K. Drug & Alcohol Drivers Training) (SA only)
10. Information for Transportation services only (Medical transport, Security Taxi, PATS, PACS, Fulton Co. Transit, Murray Transit) (MR/DD)
11. Other (MR/DD) _________________________________________
12. Other (MR/DD) _________________________________________
For those who may receive medication prescriptions through our agency, information regarding your prescriptions will be shared with Adio Consulting. This company works with us to help provide the most efficient system of medication management possible. Only information regarding your prescriptions will be shared with them.
· Method of Contact: Unless you provide us with alternative instructions, we may
call and/or mail information to your home.
· Transportation: You will be given the opportunity to designate who you wish to be allowed to transport you to and from your treatment services. By designating someone to transport you, you will be divulging your status as a consumer of our agency.
Exceptions: The law allows us to use/disclose your protected health information without your consent in certain situations. For example, we may disclose your information if needed for emergency treatment, if it is not reasonably possible to obtain your consent prior to the disclosure and we think that you would give consent if able. Also, if we are required by law to provide your treatment, we may use/ disclose your information for treatment, payment, and operations without obtaining your prior consent.
Uses and disclosure Requiring Authorization:
For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.
Uses And Disclosures Of Your Protected Health Information From Mental Health/Mental Retardation Records Not Requiring Consent or Authorization:
The law provides that we may use/disclose your protected health information from mental health and mental retardation records without consent or authorization in the following circumstances:
· When required by law: We may disclose protected health information when a
law requires that we report information about suspected abuse, neglect or domestic violence, or relating to potential criminal activity, or in response to a court order. We must also disclose information to authorities that monitor compliance with these privacy requirements.
· For public health activities: We may disclose protected health information when
we are required to collect information about disease or injury, or to report vital statistics to the public health authority.
· For health oversight activities: We may disclose protected health information to
our regional office, the protection and advocacy agency, or any other agency responsible for monitoring the health care system for such purposes as reporting or investigating of unusual incidents.
· Relating to decedents: We may disclose protected health information relating to
an individual’s death to coroners and/or medical examiners.
· To avert threat to health or safety: In order to avoid a serious threat to health
safety, we may disclose protected health information as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
· For specific government functions: We may disclose protected health
information of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.
Uses and Disclosures of Protect Health Information from Alcohol and Other Drug Records Not Requiring Consent or Authorization: The law provides that we may use/disclose protected health information from alcohol and other drug records without consent or authorization in the following circumstances:
· When required by law: We may disclose protected health information when a
law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the premises or against program personnel, or in response to a court order.
· Relating to decedents: We may disclose protected health information relating to
an individual’s death if state or federal law requires the information for collection
of vital statistics or inquiry into cause of death.
· To avert threat to health or safety: In order to avoid a serious threat to health
or safety, we may disclose protected health information to law enforcement when a threat is made to commit a crime on the program premises or against program personnel.
Your Rights Regarding Protected Health Information: You have the following rights regarding protected health information we maintain about you:
· Right to request restrictions on uses/disclosures: You have the right to ask that
we limit how we use or disclose your protected health information. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we agree to any restrictions on use/disclosure of your information, we will put the agreement in writing and abide by them, except in emergency situations. Additionally, we cannot agree to limit uses/disclosures that are required by law.
· Right to choose how we contact you: You have the right to ask that we send you
information at an alternative address or by alternative means. We will put the request in writing. We must agree to your request as long as it is reasonably easy for us to do so.
· Right to inspect and copy your protected health information: Unless your
access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put the request in writing. We will respond to your request within 14 days. If we deny access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your protected health information, a charge for copying may be imposed, depending on your circumstance. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.
· Right to request amendment of your protected health information: If you
believe there is a mistake or missing information in our record of your protected health information, you may request, in writing, that we correct or add to the record. We may deny the request if we determine that the protected health information is (i) correct and complete; (ii) not created by us and/or not part of our records, or, (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that your provide, appended to your protected health information. If we approve the request for amendment, we will change the protected health information and so inform you, and tell others that need to know about the change.
· Right to find out what disclosures have been made: You have the right to get a
list of when, to whom, for what purposes, and what content of your protected health information has been released other than for treatment, payment or health care operations. The list will not include any disclosures made on/or before April 14, 2003. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list per year. Your request must be in writing. There may be a charge for more frequent requests.
· Right to a paper copy of this notice: You have the right to receive a paper copy
of this Notice.
Complaints:
If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may file a complaint with our Privacy Officer (Chief Operations Officer) by calling (270)442-7121 or sending a written complaint to Four Rivers Behavioral Health 425 Broadway Suite 201, Paducah, KY 42001 Attn: Chief Operations Officer. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. We will take no retaliatory action against you if you make such a complaint.
Effective Date: This notice is effective on April 14, 2003 and has been revised on January 1, 2005.