NOTICE OF PRIVACY PRACTICES
This notice describes how medical, health,
and behavioral health information about you may be used and disclosed, and how
you can get access to this information.
Please review it carefully.
EFFECTIVE DATE:
This notice tells
you about the ways in which we may use and disclose health and treatment
information about you. It also describes
your rights and certain obligations we have regarding the use and disclosure of
health and treatment information.
HOW WE MAY USE OR DISCLOSE HEALTH AND TREATMENT INFORMATION ABOUT YOU
The following
information describes different ways we use and disclose health and treatment
information
For Treatment: We
may use health and treatment information about you to provide you with
behavioral health treatment or services.
We may disclose information about you to psychiatrists, therapists, case
managers, your primary care physician, and other behavioral health
professionals involved in your care. For
example, a psychiatrist treating you may need to know if you have allergies to
certain medications. Your primary care
physician may need to know what psychiatric medications you are using to
coordinate care, or we may need to speak to the pharmacist about your
prescriptions. Different departments or
groups within our Center may also share information in order to coordinate the
services you need, such as medications, individual therapy, group therapy, and
case management. We may ask for you to
authorize a release of information for some treatment disclosures even though
it is not required as a way to inform and involve you with the course of your
treatment.
For Payment: We
may use and disclose health and treatment information about you so we may bill
for the services you receive and collect from appropriate payers, such as
Colorado Mental Health Services (CMHS), Medicaid, an insurance company, or
other third parties. For example, we may
need to give the agency paying for your care information about the treatment
you received in order for them to pay.
We may also need to request prior approval or authorization to determine
whether your insurance or the responsible payer will cover services.
For Health Care Operations: We
may use and disclose health and treatment information about you for the
business activities of the
Individuals Involved in Your
Care: We may release health or treatment
information about you to a family member, actively involved in your care or
treatmen, as allowed by Colorado law (CRS 27-10-120 and 27-10-120.5). This information is limited and may only be
released when it is determined to be in your best interests.
Research: Under
certain limited circumstances, we may use and disclose health or treatment
information about you for research purposes.
For example, a research project may involve the care and recovery of all
clients who use one medication for the same condition. All research projects are subject to special
approval. We will ask for your specific
permission if the researcher will have access to your name, address or other
information that reveals who you are.
You may participate in research or not, as you wish, without
jeopardizing your care.
Appointment Reminders: We
may use and disclose information to contact you as a reminder that you have an
appointment for treatment or services.
Health-Related Information
or Resources: We may use and disclose information in order
to tell you about other resources or treatment information that may be of
interest to you, such as new groups or websites.
HIV INFORMATION: All
medical information regarding HIV is kept strictly confidential and released
only in accordance with the requirements of state law (CRS
RIGHTS OF MINORS: A
person aged 15 or older may consent to mental health treatment and authorize
disclosure of information as if s/he were an adult. Parents or legal guardians,
however, are legally entitled to request and receive information about a
minor’s mental health treatment without the minor’s permission. All other
provisions of the privacy notice apply equally to adults and to minors.
SPECIAL CIRCUMSTANCES
Federal and state laws allow or require the Center and its providers to
disclose health or treatment information about you, other than HIV information,
without your written authorization in certain special circumstances, if they
occur.
Public Health Risks (Health and Safety for You and/or Others). We may disclose health information about you
for public health activities, when necessary to prevent a serious threat to
your health and safety or to the health and safety of another person or the
general public. These activities
generally include the following:
·
To prevent or control disease, injury, or disability
·
To report births or deaths
·
To report child abuse or neglect
·
To report abuse of the elderly or at-risk adults
·
To report reactions to medications
·
To notify people of recalls of medications they may
be using
·
To notify a person who may have been exposed to a
disease or who may be at risk for contracting a disease
·
To avert a serious threat to the health or safety of
a person or the public
·
When required by law, to inform the appropriate
authorities if we believe a client has been the victim of abuse, neglect, or
domestic violence
Health Oversight Activities. We may disclose
health information about you to a health oversight agency for activities
authorized by law. These oversight
activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government
to monitor the behavioral health care system, government-funded programs, and
compliance with civil rights and other laws.
Lawsuits and Disputes: If you
are involved in a lawsuit or legal action, we may disclose health information
about you in response to a court or administrative order from a judge. We may also disclose health information about
you in response to a subpoena, discovery request or other lawful process
initiated by someone else involved in the dispute. If you have filed a complaint or lawsuit
against your therapist or the Center, health information about you may be
disclosed to resolve the matter.
Law Enforcement: We may
disclose health information about you if asked to do so by law enforcement for
one of the following reasons:
·
In response to a court order, subpoena, warrant,
summons, or similar lawful process
·
When limited information is needed to identify or
locate a suspect, fugitive, material witness, or missing person
·
About the victim of a crime if, under certain
limited circumstances, we are unable to obtain the person’s authorization
·
About a death we believe may have been the result of
criminal conduct
·
About criminal conduct at any Center office, in any
Center program, or against a staff member, visitor, or another client
·
In emergency circumstances to report a crime, the
location of the crime or victims, or the identity, description, or location of
the person believed to have committed the crime
Coroners, Health Examiners, and Funeral Directors: We may disclose information to a coroner or
health examiner. This may be necessary
to identify a deceased person or determine the cause of death. We may also release health information about
clients to funeral directors when necessary to carry out their duties.
National Security and Intelligence Activities: We may disclose health information about you
to authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective services for the President and Others: We may disclose health information about you
to authorized federal officials so they may provide protection to the
President, other authorized persons, or foreign heads of state.
As Required By Law: We will disclose health information about you when
required to do so by federal, state or local law.
YOUR RIGHTS REGARDING HEALTH
INFORMATION ABOUT YOU:
Right to Inspect and Copy: You
have the right to inspect and copy health information that may be used to make
decisions about your care. This may
include evaluations/assessments, treatment plans, progress notes, and billing
information. To inspect or copy your
health information, you must submit a request in writing to the Privacy
Officer. You may be charged a reasonable
fee for the costs of copying your records.
Your request to inspect and copy your information may be denied in
certain very limited circumstances. In
those circumstances, the Center retains the right to withhold information that
may be detrimental to your health or safety or to the health or safety of
others. If you are denied access to any
part of your health information, you may request that the denial be
reviewed. Instructions on how to
initiate that review process will be provided in writing at the time on any
denial of your access to information.
Right to Amend: If
you feel any health information we have abut you is incorrect or incomplete,
you may ask us to amend the information.
You have the right to request an amendment for as long as your health
information is kept by the Center. To
request an amendment, submit the request in writing to the Privacy
Officer. You must provide a reason that
supports your request. We may deny your
request if you ask us to amend information that
·
Is
accurate and correct
·
Is not
part of the health information kept by the Center or its providers
·
Is not
part of the health information which you would be permitted to inspect or copy
·
Was not
created by us, unless the person/entity that created the information is no
longer available to make the amendment
Right to an Accounting of
Disclosures: You have the right to request an accounting
or list of disclosures of health information made about you. The list does not include information
disclosed for the purposes of treatment, payment or health care operations, and
it does not include information disclosed on the basis of a written
authorization for release of information signed by you or someone authorized to
act for you. To request this accounting,
you must make your request in writing to the Privacy Officer. Your request must state a period of time for
the accounting that may not be longer than six years and may not include dates
before
Right to Request
Restrictions: You have the right to request a restriction
or limitation on the health information we use or disclose about you. The Center is not required to agree to your
request. If we do agree, we will comply
with the request unless the information is needed to provide you emergency
treatment. To request restrictions, you
must make your request in writing to the Privacy Officer. In your request, you must tell us what
information you want to limit, and to whom you want the limit to apply.
Right to Request
Confidential Communications: You have the right to request
that we communicate with you about health matters in a certain way or at a
certain location. For example, you can
ask that we only contact you at a certain telephone number or address. To request confidential communications, you
must submit your request in writing to the Privacy Officer. We will accommodate all reasonable
requests. Your request must specify how
or where you wish to be contacted.
Right to Paper Copy of this
Notice: You have the right to receive a paper copy of
this Notice. You may ask for one at any
time.
OTHER USES
Other uses and
disclosures of health information not covered by this notice or the laws that
apply to mental health and substance abuse providers will be made only with
your written authorization for release of information. If you provide us with such a written
authorization, you may revoke it in writing at any time. The Center will no longer use or disclose
information for the reasons covered in your authorization(s). However, the Center is unable to take back
any disclosure that was already made in reliance on your authorization.
CHANGES TO THIS NOTICE
COMPLAINTS AND ASSISTANCE
If you need any
assistance to understand this notice or your rights, and if you need assistance
in filing requests, you may ask your clinician, the consumer advocate, or the
privacy officer. If you believe your
privacy rights have been violated, you may contact the Privacy Officer for
_______________________________________________________ _________________________________
Client Signature Date
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Center Personnel
Signature Date