|
Quest Recovery & Prevention Services’ Privacy
Notice Regarding the Use and Disclosure of Protected Health
Information Effective April 14, 2003
This notice describes how medical, psychiatric, drug and
alcohol treatment-related information about you may be used
and disclosed and how you can get access to this information.
Please review it carefully.
What is Protected
Health Information (PHI)?
1.Anything from the
past, present, or future;
2.About your mental or physical
health or condition;
3.That is spoken, written, or
electronically recorded (like in a computer), and
is:
4.Created by or given to anyone providing care to you;
a health plan; a public health authority; your employer; your
insurance company; your school or university; state or federal
agencies which pay for all or part of your services; or anyone
who processes health information about you.
Your
Protected Health Information, including payment for
healthcare, is protected by two federal laws: The Health
Insurance Portability and Accountability Act of 1996
(“HIPAA”), 42 U.S.C. § 1320d et seq., 45 C.F.R. Parts 160
& 164; and the Confidentiality Law, 42 U.S.C. § 290dd-2,
42 C.F.R. Part 2. Under these laws, Quest Recovery &
Prevention Services may not say to a person outside Quest
Recovery & Prevention Services that you attend the
program, nor may Quest Recovery & Prevention Services
disclose any information identifying you as an alcohol or drug
abuser, or disclose any other Protected Health Information
except as permitted by federal law.
What Rights
Do I Have About My Protected Health
Information?
1.You have the right to consent to
the use and disclosure of your Protected Health Information
for the limited purpose of diagnosing you and administering
and paying for your treatment.
2.You have the right to
authorize the sharing of your protected Health Information for
other purposes.
3.You have the right to see a copy of your
protected Health Information. This request must be in writing.
Exceptions to this information are psychotherapy notes;
information prepared for certain legal proceedings; and
information maintained by clinical laboratories.
4.You have
the right to request that we amend your protected Health
Information. This request must be in writing.
5.You have
the right to be informed about and to share your Protected
Health Information in a confidential manner chosen by you. The
manner you choose must be possible for us to do. The request
for the manner you chose must be in writing.
6.You have the
right to restrict how we use and disclose your Protected
Health Information. We do not have to agree to your
restrictions. If we do agree, we must follow your
restrictions. The request for your restrictions must be in
writing.
7.You have the right to obtain a copy of a record
of certain disclosures of your Protected Health Information
that we make. This request must be in writing. If you request
a copy of the information we have 60 days to comply and we may
charge a reasonable fee for the costs of copying, mailing or
other supplies associated with your request.
8.You have a
right to a copy of this Privacy Notice. We may change the
terms of this Privacy Notice from time to time. You can always
get a copy of the current Privacy Notice by requesting it from
the receptionist at any Quest Recovery & Prevention
Services
office.
Consent
What can be
done with my information if I consent to disclose it for my
diagnosis or to administer and pay for my
treatment?
With your consent, we can share
information about your health with other specialists so that
you can receive the most appropriate treatment. For example,
your counselor could share with your treating physician that
you are depressed. The doctor could then prescribe medication
to help you feel better.
With your consent, we can
share information about when and for what purpose you were
seen, so that we can be paid for treating you. For example, we
could send a form to your insurance company stating when and
for what condition you were at the office. They can then send
us money to cover your costs of being seen.
With your
consent, we can share information with other healthcare
entities to ensure that you obtain the correct diagnosis. For
example, if you were complaining about being tired all the
time, we could obtain a sample of your blood and send it to a
blood laboratory. The blood laboratory could send us back
information that your blood sample contained high sugar
levels. This could help us determine whether you have
diabetes.
Can I revoke my
consent?
Yes. You can revoke your consent. You
must do this in writing and bring it to us so that we can stop
using and disclosing your Protected Health Information. We are
permitted to use and disclose your Protected Health
Information based on your consent until we receive your
revocation in writing. However, if you revoke your consent, we
reserve the right to refuse to provide further services to
you, on the basis of your refusal to allow us to share your
information for purposes of treatment, payment, and healthcare
operations.
Are there circumstances when my
information can be shared without my consent?
1.In
an emergency so long as consent is obtained as soon as
possible after the emergency.
2.When required by
law:
a.For public health activities according to
specific requirements.
b.To protect victims of abuse,
neglect or domestic violence according to specific
requirements.
c.For health oversight activities according
to specific requirements.
d.For judicial and administrative
proceedings according to specific requirements.
e.For law
enforcement purposes according to specific
requirements.
f.To a coroner/medical examiner according to
specific requirements.
g.To a funeral director according to
specific requirements.
h.For organ/eye/tissue donation
according to specific requirements.
i.For research purposes
according to specific requirements.
j.To avert serious
threats to health or safety according to specific
requirements.
k.To facilitate specialized government
functions according to specific requirements.
l.To
correctional institutions for specific reasons according to
specific requirements.
m.To facilitate eligibility
determinations or enrollment into public benefit programs
according to specific requirements.
n.For Workers
Compensation according to specific requirements.
3.
When there are substantial communication barriers and it is
reasonable to believe that you are giving your
consent.
What about any other uses of my
medical information?
Other uses and disclosures of
medical information not covered by this notice or the laws
that apply to us will be made only with your written
permission. If you provide us permission to use or disclose
medical information about you, you may revoke that permission,
in writing, at any time. If you revoke your permission, we
will no longer use or disclose medical information about you
for the reasons covered by your written authorization. You
understand that we are unable to take back any disclosures we
have already made with your permission, and that we are
required to retain our records of your care that we
provided.
What will you do to protect my health
information?
We will maintain the privacy of your
Protected Health Information as required by law. At your
request, we will provide you with a Privacy Notice containing
our legal responsibilities and privacy practices regarding
Protected Health Information.
We will follow the terms
of the Privacy Notice currently in effect.
We reserve
the right to change the terms contained in this Privacy
Notice. If we do this, it will affect all Protected Health
Information maintained by us. We will notify you that we have
changed the Privacy Notice by posting it at our offices, and
by mailing it to you at the address you
provide.
What can I do if I have questions or
want to complain about the use and disclosure of my Protected
Health Information?
If you believe your Privacy
Rights under HIPAA have been violated, all questions and
complaints may be directed to:
1341 Market Avenue
North
Canton, OH 44714
Phone: 330-453-8252
You
may also complain to the Secretary of the United States
Department of Health & Human Services.
By law, we
may not retaliate against you for complaining about the use or
disclosure or your Protected Health
Information.
Acknowledgment
I
hereby acknowledge that I received a copy of this
notice.
____________________________________________
Signature
of Client
______________________
Date |
