NOTICE OF PRIVACY PRACTICES
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.
WHO WILL FOLLOW THIS NOTICE
This Notice describes the Alcott Center for Mental Health Services’ (ACMHS’) practices and that of:
All employees, staff and other ACMHS personnel.
Any volunteers we allow to serve you while you are at the agency.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We
are committed to protecting medical information about you. We create a record
of the care and services you receive at the agency. We need this record to
provide you with quality care and to comply with certain legal requirements.
This Notice applies to all of the records of your care generated by the Alcott
Center for Mental Health Services. As required and when appropriate, we will
ensure that the minimum necessary information is released in the course of our
duties.
This Notice will tell you about the ways in which we may use and disclose
medical information about you.
We also describe your rights and certain obligations regarding the use and
disclosure of medical information.
We are required by law to:
Make sure your medical information, also known as “protected health information” or “PHI”, is kept private;
Give you this Notice of our legal duties and privacy practices with respect to
your PHI; and
Follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following categories describe different ways that we use and disclose
protected health information.
For each category of uses or disclosures we will explain what we mean and try to
give some examples. Not every use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose information will
fall within one of the categories.
For Treatment
We create a record of the treatment and services you receive at our agency. We
may use your PHI to provide you with medical treatment or services. We may
disclose your PHI to case managers, therapists, volunteer interns, or other
agency personnel who are involved in taking care of you at the center. For
example, your therapist may share PHI with your case manager in order to
coordinate the different things you need, such as a psychiatrist appointment, a
medical exam, or a lab test.
We also may disclose your PHI to people outside the agency who may be involved
in your treatment, such as your psychiatrist, or your coordinating case
manager, for coordination and management of your health care. For example, your
therapist may share information with your psychiatrist about your response to a
new medication, in effort to evaluate the effectiveness of your treatment. Your
mental health information may only be related to health care professionals
outside this agency without your authorization if they are responsible for your
physical or mental health care.
For Payment
We may use and disclose your PHI in order to get paid for the treatment and
services we have provided you.
For example, we may need to give your health plan information about a visit, or
treatment session you received at the agency so your health plan will pay us.
We may also tell your health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your plan will cover the
treatment.
For Health Care Operations
We may use and disclose your PHI to carry out activities that are necessary to
operate our organization and to make sure that all of our clients receive
quality care. For example, we may use medical information to review our
treatment and services and to evaluate the performance of our staff in caring
for you. We may also combine medical information about many agency clients to
decide what additional services the agency should offer, what services are not
needed, and whether certain new treatments are effective. We may also disclose
information to our accountants, attorneys, student trainees and other ACMHS
personnel for review and learning purposes. We may also combine the information
we have from other agencies to compare how we are doing and see where we can
make improvements in the care and services we offer.
Appointment Reminders, Treatment Alternatives, and Health-Related Products and
Services
We may use and disclose your PHI to provide appointment reminders or give you
information about treatment alternatives. We may also use and disclose PHI to
tell you about health-related benefits or services that may be of interest to
you (for example, Medi-Cal benefits).
Fundraising Activities
We may use PHI about you to contact you in an effort to raise money for our
programs, services and operations
. We may disclose medical information to a foundation related to the agency so
that the foundation may contact you in raising money for the agency.
If you do not want us to contact you for fundraising purposes, you must notify
the Executive Director in writing. Please state clearly that you do not want to
receive any fundraising solicitations from us.
HOW WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION, BUT FOR WHICH
YOU WILL HAVE OPPORTUNITY TO OBJECT
Individuals Involved in Your Care or Payment for Your Care
We may disclose your PHI to a friend or family member that you indicate is
involved in your medical care or the payment for your care. In addition, we may
disclose your PHI to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status, and location. You may
object to this disclosure with a written request. However, if you are not
available or are unable to agree or object, or in some emergency circumstances
, we will use our professional judgment to decide whether this disclosure is in
your best interest.
HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU THAT DOES NOT REQUIRE YOUR
AUTHORIZATION OR OPPORTUNITY TO OBJECT
As Required by Law
We will disclose your PHI when required to do so by federal, state or local law.
Workers’ Compensation
We will disclose your PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks
We may disclose your PHI for public health activities, such as those aimed at
preventing or controlling disease, preventing injury or disability, and
reporting the abuse or neglect or children, elders and dependent adults.
Health Oversight Activities
We may disclose your PHI to a health oversight agency for activities authorized
by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for
the government to monitor the health care system, government programs, and
compliance with civil rights.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose your PHI in
response to a court or administrative order. We may also disclose your PHI in
response to a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell you
about the request (which may include written notice to you) or to obtain an
order protecting the PHI requested.
Law Enforcement
We may disclose PHI to government law enforcement agencies in the following
circumstances:
In response to a court order, warrant, subpoena, summons or similar process
issued by a court.
In order to prevent a serious threat of violence to another person.
Also, if you have been admitted to a residential facility and have disappeared.
Coroners, Medical Examiners and Funeral Directors
We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine
the cause of death.
We may also release PHI about clients of the agency to funeral directors as
necessary to carry out their duties.
Specialized Government Functions
We may disclose your PHI to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
We may disclose your PHI to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state
or conduct special investigations. We may disclose PHI of military personnel
and veterans in certain situations.
Research
Under certain circumstances, we may use and disclose your PHI to medical
researchers who request it for approved medical research purposes. All
potential research projects are subject to an approval process that evaluates
the project
’s use of PHI with the client’s need for privacy of their PHI.
Inmates
If you are an inmate or under the custody of a law enforcement official, we may
release your PHI to the correctional institution or law enforcement official.
This release would be necessary (1) for the institution to provide you with
health care; (2) to protect your health and safety or the health and safety of
others; or (3) for the safety and security of the correctional institution.
HOW WE MAY USE AND DISCLOSE PHI WITH YOUR AUTHORIZATION
Other uses and disclosures of your PHI not covered by this Notice or the laws
that apply to us will be made only with your written authorization.
If you provide us authorization to use or disclose your PHI, you may revoke that
authorization, in writing, at any time.
If you revoke your authorization, we will no longer use or disclose your PHI for
the reasons covered by the authorization, except that, we are unable to take
back any disclosures we have already made when the authorization was in effect,
and we are required to retain our records of the care that we provided to you.
RIGHTS REGARDING YOUR PHI
You have the following rights regarding your PHI in our records:
Right to Inspect and Copy
With certain exceptions, you have the right to inspect and copy your PHI from
our records. Usually, this includes treatment and billing records, but may not
include some mental health information.
To inspect and copy PHI that may be used to make decisions about you, you must
submit your request in writing to the Program Manager. We will provide you a
form for this request. If you request a copy of your PHI, we may charge a fee
for the costs of copying, mailing or other supplies associated with your
request.
We may deny your request to inspect and copy in certain circumstances. If you
are denied the right to inspect and copy your PHI in our records, you may
request that the denial be reviewed. With the exception of a few circumstances
that are not subject to review, another licensed health care professional
within ACMHS, who was not involved in the denial, will review the decision. We
will comply with the outcome of the review.
Right to Request Amendment
If you feel that your PHI in our records is incorrect or incomplete, you may ask
us to amend the information. You have the right to request an amendment for as
long as we keep the PHI.
To request an amendment, ask for a Request to Amend Protected Health Information form, and complete and submit this form to the Program Manager. In addition, you
must provide a reason that supports your request.
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 PHI that:
Was not created by us, unless you can provide us with a reasonable basis to
believe that the person or entity that created the PHI is no longer available
to make the amendment;
Is not part of the PHI kept by or for the agency;
Is not part of the PHI which you would be permitted to inspect and copy; or
Is accurate and complete.
If we deny your request for amendment, you have the right to submit a Statement of Disagreement form, with a description not to exceed 250 words, with respect to any item or
statement in your record you believe is incomplete or incorrect. If you clearly
indicate in writing that you want this form to be made part of your medical
record, we will attach it to your records and include it whenever we make a
disclosure of the item or statement you believe to be incomplete or incorrect.
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 your PHI other than our own uses for treatment,
payment and health care operations, as those functions are described above, and
with other exceptions pursuant to the law.
To request this list or accounting of disclosures, ask for a Request for an Accounting of Disclosures form and complete and submit this form to the Program Manager. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For
additional lists, we may charge 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 that we follow additional, special restrictions
when using or disclosing your PHI for treatment, payment or health care
operations. You also have the right to request that we follow additional,
special restrictions when using or disclosing your PHI to someone who is
involved in your care or the payment for your health care, like a family member
or friend. For example, you could ask that we not use or disclose that you are
receiving services at this agency.
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, ask for a Request for Additional Restrictions on Use or Disclosure of Protected Health
Information
form, and complete and submit this form to the Program Manager. In your request,
you must tell us (1) what information you want to limit; (2) whether you want
to limit our use, disclosure or both; and (3) to whom you want the limits to
apply, for example, disclosures to your spouse.
Right to Request Confidential Communications
You have the right to request that we communicate with you about your
appointments or other matters related to your treatment in a specific way or at
a specific location. For example, you can ask that we only contact you at work
or by mail.
To request confidential communications, ask for a Request to Receive Confidential Communications by Alternative Means or at
Alternative Location
form, and complete and submit this form to the Program Manager. Your request
must specify how or where you wish to be contacted. We will not ask you the
reason for your request. We will accommodate all reasonable requests.
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 this Notice electronically, you are still
entitled to a paper copy of this Notice.
You may obtain a paper copy of this Notice from the front desk receptionist or
your case manager.
You may also obtain a copy of this Notice at our website: www.alcottcenter.org.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice. We reserve the right 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 copy of the current Notice in the reception area and other
visible locations in the facility.
The Notice will contain on the last page, bottom left hand corner, the effective
date.
If we change our Notice, you may obtain a copy of the revised Notice by visiting
our website at
www.alcottcenter.org, or you may request one from your case manager.
TO GET MORE INFORMATION OR TO FILE A COMPLAINT
If you believe your privacy rights have been violated, you may file a written
complaint with our Privacy Officer. You also may file a written complaint with
the U.S. Department of Health and Human Services at 50 United Nations
Plaza-Room 322, San Francisco, CA 94102
. You will not be penalized or retaliated against for filing a complaint. To file a complaint with us, or if you have comments or questions regarding our
privacy practices, contact:
Alcott Center for Mental Health Services
Privacy Officer
1433 South Robertson Blvd.
Los Angeles, California 90035
(310) 785-2121
Effective Date: April 14, 2003