Behavioral Healthcare Services Privacy Notice

Consumer Acknowledgement Receipt

( Required for the Above Receipt)

Your Privacy is Important

BHS understands your privacy is important. Any and all information we receive about you will be used only to assist you. We will handle this information only as allowed by federal/state law and agency policy.

If at any time you believe your privacy rights have been violated, you may verbally or in writing contact:

• Agency’s Privacy Officer
• State Advocate
• Secretary of Health and Human Services

Address and phone numbers to use are listed on the third page of this notice. You will not experience a change in services or retaliation for filing a complaint.

Each time you receive services from us, the provider makes a record of the visit. Typically, this record contains your assessment, service plan, progress notes, diagnoses, treatment, and plan for future care or treatment.

Your Federally Defined Rights under HIPAA

There are several rights concerning your health information in the medical record that we want you to be aware of:

• There are several rights to request access to your medical record in order to inspect, copy, amend, or correct it. This process will be kept confidential. This right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You may make this request to your Primary Service Coordinator or the agency’s Consumer Services Coordinator.
• You have the right to receive at any time an accounting of the agency’s disclosure of your medical record.
• You have the right to request a restriction with regards to the use or disclosure of your medical record. This request will be given serious consideration and you will be informed promptly whether we will be able to use the restriction and still offer effective services, receive payment and maintain health care operations. Legally we are not required to abide by any restrictions you request.

Use and Disclosure of Your Information

Upon signing the agency’s Consent to Treatment/Service form, you are allowing us to use and disclose necessary information about you within the agency and with business associates in order to provide treatment/service, receive payment of provided treatment/service, and conduct our day to day business practices.

In order to effectively provide treatment/service, our Primary Service Coordinator may consult with various service providers within the agency. During those consultations health information about you may be shared.

In order to receive payment of services provided, your health information may be sent to those companies or groups responsible for payment coverage, and a monthly bill is sent to the Responsible Party identified by you and noted on the financial form.

In day-to-day business practices, trained staff may handle your physical medical record in order to have the record assembled, available for review by the Primary Service Coordinator, or for filing of documentation. Certain data elements are entered into our computer system that processes most billing, and for state statistical reporting to DMHMRSAS. As a part of our continuous Quality Improvement efforts to provide the most effective services, your record may be reviewed by professional staff to assure accuracy, completeness and organization.

Enhancing Your Healthcare

Some agency programs provide the following support to enhance your overall health care:

• Appointment reminders by call or letter
• Describing or recommending treatment/service alternatives
• Providing information about health-related benefits and services that may be of interest to you.

Specific Circumstances for Disclosure without Authorization

We are allowed by federal and state law in certain circumstances to disclose specific health information about you without your consent, authorization, or opportunity to agree or object. There may be documentation available to you upon your request listing what information was disclosed, to whom and for what reason.

These specific circumstances are:

• As required by law (ex: Court-ordered warrant or subpoena)
• Public Health authorities for authorized activities (ex: Communicable diseases)
• Judicial and Administrative proceedings (ex: Order from a court or administrative tribunal)
• Law Enforcement purposes (ex: reporting of gun shot wounds; limited information requested about suspects, fugitives, material witnesses, missing persons; witnesses criminal conduct on premises)
• To avert a serious threat to Health and Safety (ex: in response to a statement made by person served to harm self or another)
• Children or incapacitated adults who are victims or Abuse, Neglect or Exploitation
• Specialized Government functions

• Military Services (ex: in response to appropriate military command)
• National Security and Intelligence activities (ex: in relation to protective services to the President of the United States)
• State Department (ex: medical suitability for the purpose of security clearance)
• Correctional Facilities (ex: to correctional facility about an inmate)

• Research (ex: for research approved by institutional review board)
• Health Oversight Activities (ex: DMHMRSAS monitoring)
• Workers Compensation (ex: facilitate processing, treatment and payment)
• Coroners and Medical Examiners (ex: for identification of a deceased person or to determine cause of death)
• Secretary of Health and Human Services (ex: secretary may monitor for HIPAA compliance)
• Emergencies (ex: serious health condition for treatment)

Other Used and Disclosures of Your Information by Authorization Only

When you request information to be disclosed to another party or yourself, we will respond in accordance with federal and state law.

We are required to get your authorization to use or disclose your protected health information for any reason other than treatment/services, payment, or health care operations, and those specific circumstances outlined previously. We use an Authorization to Use/Disclose form that specifically states what information will be given to whom, for what purpose, and is signed by you or your legal representative. You have the ability to revoke the signed authorization at any time by a written statement given to use to that effect.

Changes to Privacy Practices

BHS reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law.

You will receive notice of changes either by mail, posting, or discussion with an agency representative or electronically or a combination of the four.

If you would like additional information concerning our Privacy Policy, or the federal and state laws pertaining to privacy, please contact: