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ACT Medical Group, PA as Agent for Area MH Programs
Notice of Privacy Practices
PRIVACY
NOTICE - EFFECTIVE JUNE 2003
We
are required by law to protect the privacy of health care information
about you and that identifies you. This may be information about health
care services that we provide to you or payment for health care provided
to you. It may also be information about your past, present, or future
health care condition. We are also required by law to provide you with
this Privacy Notice explaining our legal duties and privacy practices with
respect to health care information. We are legally bound to follow the
terms of this Notice. In other words, we are only allowed to use and
disclose health care information in the manner that we have described in
the Notice. We may change the terms of this Notice in the future. We
reserve the right to make changes and to make the new Notice effective for
all health care information that we maintain. If we make changes to the
Notice, we will:
- Have
copies of the new Notice available upon request
- Post
the new Notice on our website located at www.actmentalhealth.com
Understanding
Your Health Record and Information
Each time you visit a
hospital, physician or other healthcare provider, a record of your visit
is made. Typically, this record contains your symptoms, examination and
test results, diagnosis, treatment and a plan for future care of
treatment. This information, which is often referred to as your health or
medical record, serves as a basis for planning your care as well as a
legal document describing the care you received.
Authorization
As a general rule, ACT
will not disclose healthcare information about you outside our
organization without authorization (signed permission) from you or your
legally responsible person/personal representative unless otherwise
permitted/required by state and federal confidentiality/privacy laws. If
you sign an authorization allowing us to disclose healthcare information
about you, you may later revoke or cancel it (except in very limited
circumstances relate to insurance coverage). If you would like to revoke
your authorization, you may do so orally to a Release of Information Clerk
or Medical Record Manager or in writing by filling out a revocation form.
You may obtain these forms from the receptionist at any ACT site. When an
authorization is revoked, ACT will follow your instructions except to the
extent that we have already relied upon your authorization and taken some
action.
How
We May Use and Disclose Your Healthcare Information
We use and disclose
healthcare information about clients every day. This section of the notice
explains in some detail how we may use and disclose healthcare information
about you in order to provide healthcare, obtain payment for healthcare
and operate our business efficiently. As stated above, as a general rule,
ACT will not use/disclose healthcare information about you outside our
organization without authorization from you unless otherwise permitted or
required by state and federal confidentiality/privacy laws. The following
offers more description and some examples of our potential
uses/disclosures of your healthcare information. If you are being seen
for a substance abuse problem, this uses/disclosure section of the privacy
notice does not apply to you. Please read the "Uses/disclosures
relating to substance abuse" section. NOTE: The rest of the sections
of this notice DO apply to you - "Rights" and "How
to file a complaint".
Treatment:
We will use your
health information for treatment. For example, information obtained about
you by a therapist, psychiatrist, case manager, nurse or other member of
your healthcare team will be recorded in your record and used to determine
the course of treatment that should work best for you. Members of your
healthcare team will also record goals that you established and the
interventions used to help you reach your goals. Your psychiatrist will
also record information about medications they have prescribed for you as
well as your response to these medications. We may disclose information to
other treatment providers that contract with us.
Payment:
We will use your
health information for payment. For example, a bill will be sent to you.
Information on the bill may include information that identifies you, as
well as your diagnosis, your treating clinician and type of services you
have received.
Healthcare
Operations: We will
use your health information for healthcare operation. For example, members
of the treatment team and quality improvement staff may use information in
your record to assess the care and outcomes in your case. This information
will be used in an effort to continually improve the quality and
effectiveness of the services we provide. We may also contact you via mail
or phone to provide you appointment reminders or information about
treatment choices and services that may be of interest to you.
Persons
Involved in Your Care:
We are required by state law to disclose limited information about you
that is relevant to your care to: your next of kin or other family member
involved in your care or other person designated by you. Some of the
disclosures require your written or oral authorization, some require only
that we notify you of the request. We may use/disclose certain
healthcare information about you without your written authorization in
limited circumstances such as: those required by law; public health
activities; health oversight activities; disclosures about abuse, neglect
or domestic violence; judicial and administrative proceedings; law
enforcement purposes; and certain government function. Please note this
list is NOT an exhaustive list and is not limited to the examples listed
below.
Examples
of Uses/Disclosures Required by Law:
We will disclose healthcare information about you whenever we are required
by law to do so. There are many federal and state laws that require us to
use/disclose healthcare information. For example, state law requires us to
report certain types of wounds we think were caused by a criminal or
violent act.
Examples
of Uses/Disclosures for Public Health Activities:
We may disclose health care information about you when
required by law for public health activities. Public health activities
require the use of medical information for various activities, including,
but not limited to, activities relating to investigating diseases,
reporting child abuse and neglect, etc. For example, if you have been
exposed to a communicable disease (such as sexually transmitted disease)
we may report it to the Health Department.
Examples
of Uses/Disclosures for Health Oversight:
We may disclose
healthcare information about you to a health oversight agency, which is an
agency responsible for overseeing the healthcare system or government
programs. For example, a government agency may request information from us
while they are investigating possible insurance fraud.
Examples
of Uses/Disclosures for Judicial/Administrative Proceedings:
We may disclose information about you in a judicial proceeding. For
example, we must disclose your healthcare information when we are
presented with a valid court order requiring disclosure.
Examples
of Uses/Disclosure for Research:
On rare occasions ACT may determine that information may be released for
research studies. Stringent guidelines would be met prior to such a
disclosure.
Examples
of Uses/Disclosures About Abuse/Neglect:
We may disclose healthcare information about you to a governmental
authority that is authorized by law to conduct an investigation regarding
abuse and/or neglect. For example, if you are an adult and we reasonably
believe that you may be a victim of abuse, neglect or domestic violence.
Examples
of Uses/Disclosures for Law Enforcement:
We may disclose healthcare information about you for law enforcement
purposes. For example, if a law enforcement officer has a magistrate order
to take you into custody for an involuntary commitment exam, we are
permitted to disclose to the officer information about your mental state
when necessary to assure your health and safety and the health and safety
of the officer transporting you.
Examples
of Uses/Disclosures for Governmental Purposes:
We may use or disclose healthcare information about you for certain
governmental function. For example, we may disclose information to the
Department of Correction if you are an inmate and need treatment.
THIS
SECTION IS FOR USES/DISCLOSURES RELATING TO SUBSTANCE ABUSE
Federal
law, 42 CFR parts 2, restricts the use and disclosure of patient
information that is received by an alcohol or drug abuse treatment
program. Generally, substance abuse information that we obtain for the
purpose of providing you substance abuse treatment, diagnosis, or referral
for treatment must not be disclosed without your written authorization.
For example, we would need your written authorization before we could
disclose substance abuse information to your insurance provider for the
purpose of obtaining reimbursement for the cost of services provided to
you. The federal law protecting substance abuse treatment information
applies only to information that would identify, a substance abuse
patient, directly or indirectly, as an alcohol or drug abuser or a
recipient of alcohol or drug services. In addition to restricting
disclosure, federal law places restrictions on the use of information to
initiate or substantiate any criminal charges against a patient or to
conduct a criminal investigation of a patient. As stated above, federal
law generally requires that we obtain your written consent before we may
disclose information that would identify you as a substance abuser or a
patient of substance abuse services. But, there are some important
exceptions to this requirement. We can disclose information within our
program to members of our workforce as needed to coordinate your care. For
example, information obtained about you by a therapist, psychiatrist,
nurse or other member of our healthcare team will be recorded in your
record and used to determine the course of treatment that should work best
for you. We may also disclose your information to agencies that help us
carry out our responsibilities in serving you with whom we have a
Qualifies Service Organization or Business Associate Agreement. We may
disclose your information within our program to carry out our healthcare
operation. For example, members of the treatment team and quality
improvement staff may use information in your record to assess the care
and outcomes in your case. We may disclose information to medical
personnel in a medical emergency. If we suspect that a child is abused or
neglected, state law requires us to report the abuse or neglect to the
Department of Social services, and we may disclose substance abuse
treatment information when making the report. We will disclose information
about you if a court orders us to do so. If you commit a crime, or
threaten to commit a crime, on the premises of our program or against our
program personnel, we may disclose information about you to talk to law
enforcement officers about the crime or threat. We also may disclose
information for research, audit or evaluations.
THE
REST OF THIS SECTION APPLIES TO ALL CLIENTS
Rights
This section of
the notice will briefly mention your privacy rights. If you would like to
know more about these rights, please contact the ACT Privacy Officer at
888-311-1254.
Right
to a Copy of Notice: You
have a right to receive a paper copy of our Notice at any time. In
addition, a copy of this Notice will always be posted on our website:
www.actmentalhealth.com.
Right
to inspect and request copy of record: In
most cases, you have the right to look at or get copies of your records.
You must make the request by writing a letter to the Privacy Officer. We
will respond to your request within 30 days. In some cases we may deny
your request. If we deny you 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 record, a charge for copying may by imposed, depending on
your circumstances. 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 to Record: If
you believe that your health information is wrong or some information is
missing in your record, you must request, in writing, that we correct or
add to the record by writing a letter to the Privacy Officer. We will
respond within 60 days of receiving your request. We may deny your request
if we determine that the information is: (1) correct and complete; (2) not
created by us and/or not part of our records, or; (3) not permitted to be
disclosed, i.e. information compiled in anticipation of a civil
proceeding. 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 you provide, added to your health information. If we approve
the request for amendment, we will change the information in your record,
inform you, and tell other who need to know about the change.
Right
to Request an Accounting of Certain Disclosures: You
have the right to request an accounting (which means a detailed listing)
of disclosures that we have made for the previous 6 years (beginning April
14, 2003). If you would like to receive an accounting, you may send a
letter requesting an accounting to the Privacy Officer. Our agency must
act on this request no later than 60 days after receipt of the request.
The accounting will not include several types of disclosures, including
disclosures for treatment, payment or health care operations. It will also
not include disclosures made prior to April 14, 2003. If you request an
accounting more that once every 12 months, we may charge you a fee to
cover the costs of preparing the accounting.
Right
to Request a Restriction of Uses or Disclosures: You
have the right to ask that we limit how we use or disclose your healthcare
information. You may make a request by submitting a letter to the ACT
Privacy Officer. We will consider your request but are not legally bound
to agree to the restriction. To the extent that we do agree to any
restriction on our uses/disclosure of your information, we will put the
agreement in writing and abide by it except in emergency situations. We
cannot agree to limit uses/disclosures that are required by law. In order
to cancel the restrictions, you must submit a request in writing. In
addition, we may cancel a restriction at any time as long as we notify you
of the cancellation and continue to apply the restriction to information
collected before cancellation.
Right
to Request an Alternate Method of Contact: You
have the right to ask that we send your healthcare or billing information
to or contact you at an address or phone number that is different that
your home. We must agree to your request as long as it is reasonably easy
for us to do so. You must make this request in writing by submitting a
letter to the ACT Privacy Officer. You do not have to explain the reason
for your request. Please be aware that if you are using a cell phone or
mobile phone, your conversations may be picked up by other cell/mobile
users.
Filing
a Complaint
How
to File a Complaint or Report a Problem: If
you believe your privacy rights have been violated or you are dissatisfied
with our privacy policies, procedures or practice, you can contact the ACT
Privacy Officer at 888-311-1254. Also, you may file a written complaint,
either on paper or electronically, with the Secretary of the U.S.
Department of Health and Human Services (DHHS) as follows:
Region
IV, Office for Civil Rights
US
Dept. of Health and Human Services
Atlanta
Federal Center, Suite 3B70
61
Forsyth Street, SW
Atlanta,
GA 30303-8909
Phone
(404)562-7886
Fax:
(404) 562-7881
TDD:
(404) 331-2867
E-Mail:
OCRCComplaint@hhs.gov
Complaints must be filed with US DHHS within 180 days of when you knew or should have known that the act had occurred. The Secretary may waive this 180-day time limit if good cause is shown. There will be no retaliation against you for filing a complaint.
For More Information: If you have questions or would like additional information, you may speak to your clinician and/ or the ACT Privacy Officer at 1-888-311-1254 ext. 34
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