Notice of Privacy Practices for Protected Health Information (PHI)
THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU OR ABOUT THE INDIVIDUAL FOR WHOM YOU ARE AN AUTHORIZED PERSONAL REPRESENTATIVE MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.
Specialized Treatment Facility (STF) is dedicated to protecting your medical information. STF is required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. STF collects health information from you and stores it in a chart or file and on a computer. This is your health record. The health record is the property of STF, but the information in the record belongs to you. If you have questions about any part of this Notice or if you want more information about the privacy practices at STF, please contact:
Effective Date of this Notice: April 14, 2003
STF is required to abide by the terms of the Notice currently in effect.
Changes to the Notice: STF reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. If STF makes a material change in this Notice, we will post the revised Notice at the Facility and will make a copy of the revised Notice available to you upon request.
Section I: Description of how STF may use or disclose your health information and examples of each:
The law permits STF to use or disclose your health information without your written consent or authorization for the following purposes:
Treatment: We may use health information about you to provide treatment and services. We may disclose your health information to doctors, nurses, technicians, or other staff at STF who are involved in taking care of you or when we refer you to another health care provider for treatment or services.
Examples: Your physician may ask a nurse to give you certain medications or information related to your condition or treatment. Another example is that if you had heart problems that required us to consult with a heart specialist (cardiologist) outside of the Facility, your doctor at STF may refer you to a cardiologist in the community for your care. The Facility would share information from your health record needed by the staff at the cardiologist’s office for your continued care. We may also release your information to another treatment facility for your continued care after your discharge from this facility.
Payment: We may use and disclose your health information to third party payers, such as insurance companies, Medicaid, or Medicare, when needed to determine your eligibility for benefits, for reimbursement or for other requirements related to payment for treatment or services.
Examples: Information on or accompanying a bill to your insurance company or a claim form to the Division of Medicaid may include information, such as your diagnosis, the dates you received the services for which payment is requested or claimed, and the procedures or services you received. Information may be disclosed and used as part of utilization review activities, such as precertification and preauthorization of services and concurrent and retrospective review of services.
Healthcare Operations: We may use your health information for the purposes of STF operations. These uses and disclosures are necessary to run or operate the Facility and to make sure that all individuals we serve receive quality care.
Examples: Your records may be copied by a secretary to send them to another healthcare provider for your continued treatment. Members of the medical/nursing staff and other staff at the Facility may review your health information to assess the care, outcomes, and quality of services you and others at the Facility receive.
Section II: Other purposes for which we are permitted or required to use or disclose your health information without your consent or authorization:
Section III: When STF may not use or disclose your health information:
Except as provided in this Notice of Privacy Practices, STF will not use or disclose your health information, including, except under certain conditions, psychotherapy notes, without your written authorization. If you do authorize the Facility to use or disclose your information for purposes other than as provided in this Notice, you may revoke your authorization in writing at any time.
Please Note: Release of information and/or other health information rights relating to substance abuse treatment/services and to nursing home services are also subject to rights and/or restrictions set out in other federal law and regulations.
Section IV: Your Health Information Rights:
You have the following rights with respect to your Protected Health Information (PHI):
Section V: How you can exercise your health information rights:
You may exercise one or more of the rights described in this Notice or receive additional information by contacting:
Section VI: Complaints:
You will not be retaliated against for filing a complaint. If you believe your health information privacy rights have been violated, you may contact any of the following:
OCR Regional Manager
Office for Civil Rights