NOTICE OF PRIVACY PRACTICES OF:
CARROLL COUNTY YOUTH SERVICE BUREAU (CCYSB)
59 Kate Wagner Road
Westminster, Maryland 21157
Phone 410.848.2500/Fax 410.876.3016
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.
If you have any questions about this notice, please contact the Compliance Officer at the address listed above.
WHO WILL FOLLOW THIS NOTICE
This notice describes information about privacy practices followed by our psychiatrist, therapists, and front office personnel. The practices described in this notice will be followed all staff with whom you consult with by telephone (when your regular
provider from our office is not available).
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the healthcare and services you receive at this office. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
Health Information, in part, includes:
Name Address Phone Number Payment for Services
Insurance #’s Social Security # Dates of Service Diagnosis Prescriptions
Basically, Protected Health Care Information is any information about a client’s/patient’s health or the payment for healthcare that can be traced back to the client/patient.
When you authorize CCYSB to provide counseling or medication management services, by signing our consent form, you give permission for CCYSB to use and disclose health information for the following purposes: (these examples are not meant to be exhaustive, but to describe the types and uses and disclosures that may be made by our office).
For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, office staff or other personnel in our office who are involved in taking care of you and your health. For example, this may include office staff typing dictation from your health care provider about you. Your counselor may tell his/her supervisor or our psychiatrist about your condition so that, together, they can determine the most appropriate care for you. Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy and working with a lab to obtain your results.
For Payment. We may use and disclose health information about you so that the treatment and services you receive at this office may be billed. Payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information details about service in order to be reimbursed for that service.
We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval, or to determine whether your plan will cover the treatment.
Should you neglect to pay for services you received at our office, we may share your protected health information with our attorney or another agency contracted to collect unpaid balances. In this case only the information that is relevant to collection will be disclosed.
For Healthcare Operations. We may use and disclose limited health information about you in order to run the office and make sure that you and our other clients/patients receive quality care. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our clients/patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
For Marketing / Fundraising: Although we are a non-profit organization and do accept donations, we will not use your protected health information for marketing or fundraising endeavors.
Appointment Reminders: We may contact you as a reminder that you have an appointment at the office.
Treatment Alternatives: We may contact you to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Products and Services: We may contact you to tell you about health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, treatment alternatives or health-related products and services.
If you advise us in writing (at the address listed at the top of this notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
You may revoke your consent to use and disclose protected health information at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures that occurred before that time. If you do revoke your consent for services, we will not be permitted to use or disclose information for purposes of treatment, payment or healthcare operations, and we may therefore choose to discontinue providing you with healthcare treatment and services.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object.
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree, or object to the use or disclosure of the protected health information, your provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree, or object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person who is responsible for your general condition. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Other Permitted and Required Uses and Disclosures that MAY Be Made WITHOUT Your Consent, Authorization or Opportunity to Object:
It is permissible for us to release the following information. To the best of our ability we will protect your privacy and confidential information by consulting with you first, unless we are required by law to respond without notification.
These situations include:
To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety, or the health and safety of another person.
Required By Law: When required to do so by federal, state or local law we will need to disclose health information about you.
Military. Veterans. National Security and Intelligence: If you are or were a member of the armed forces, or part of the national security or intelligence communities, when the appropriate conditions apply, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority. We will make a strong effort to contact you as soon as we receive such a request so you have the opportunity to object.
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. We will make a strong effort to contact you as soon as we receive such a request so you have the opportunity to object via your attorney.
Public Health Risks: We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; suspected abuse or neglect, non-accidental physical injuries or reactions to medications.
Health Oversight Activities: We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena. We will make a strong effort to contact you as soon as we receive such a request so you have the opportunity to object via your attorney.
Law Enforcement: We may release health information, so long as applicable legal requirements are met, if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements. We will make a strong effort to contact you as soon as we receive such a request so you have the opportunity to object via your attorney.
Information Not Personally Identifiable: We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in a reasonable anticipation of, or use in a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You must submit a written request to our compliance officer in order to inspect and/or copy your health information. If you request a copy of the information, we will charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend: If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.
To request an amendment, obtain a “Medical Record Amendment/Correction” form from our receptionist, complete and submit it to our compliance officer.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and healthcare operations. To obtain this list, you must submit your request in writing to our clinical director. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want
the list (for example, on paper or electronically). One request for an Accounting of Disclosures per year is available to you at no charge. Additional requests will incur a charge to you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care, or the payment for it, like a family member. For example, you could ask that we not use or disclose information about your appointment schedule at this office. We are not required to agree to your request: If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the “Request For Restriction On Use/Disclosure Of Medical Information” form to our compliance officer.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you may complete and submit the “Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication” form to our compliance officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact our receptionist.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the
office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
If you believe your privacy rights have been violated, you may file a complaint with our Compliance Officer at the address found at the top of this notice. You will not be penalized for filing a complaint. If you feel the issue was not resolved after talking with our Compliance Officer, you may file a complaint, submitted in writing, with the Secretary the Department of Health and Human Services.
This notice was published and becomes effective on April 14, 2003.