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PERSONAL INFORMATION WE COLLECT

We ask people seeking services and/or benefits to provide certain information when they complete an enrollment form.  This information may include: (1) name, address and phone number, (2) date of birth, (3) marital status,  (4) social security number, and (5) family income.

We may also receive personal information about you from others, such as: (1) Crisis Care, (2) insurance Companies, (3) other government agencies (criminal justice system) and (4) all other referral sources.

HOW MAY WE USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical 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 these categories.

·           For Treatment    We may use medical information about you to provide you with medical treatment or services.  We may disclose medical information about you to doctors, nurses, counselors, healthcare professionals in training, or other agency personnel who are involved in your care or who coordinates the different things you need such as prescriptions, counseling, and residential support.

·           For Payment    We may use and disclose medical information about you so that the treatment and services you receive at the agency may be billed to and payment may be collected from you, an insurance company or a third party so that we can get payments for the services provided.

·           For Healthcare Operations    We may use and disclose medical information about you for agency operations.  These uses and disclosures are necessary to run the agency and make sure that all of our clients receive quality care.  We may also combine medical information about many clients to decide what services to offer, but we will remove information that identifies you from this set of medical information so others may use the it without learning who the specific clients are.

SHARING YOUR PERSONAL INFORMATION:

• We may also use your personal information to:

• To protect victims of abuse, neglect or domestic violence

• To reduce or prevent a serious threat to public health and safety

• For health oversight activities such as investigations, audits and inspections

• For local, state and federal agencies to monitor your services

• For lawsuits and similar proceedings

• For public health purposes such as reporting communicable diseases, work-related illnesses, or other diseases and   injuries permitted by law; reporting births and deaths and reporting reactions to drugs and problems with medical devices

• Review and evaluate the quality, effectiveness, and efficiency of the services you have received

• Conduct programs and/or audits of programs

• Investigate and report major unusual incidents, take steps to protect your health and safety

• Prepare reports required by the Ohio Department of Alcohol and Drug Addiction Services and the Department of Job and  Family Services

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy    You have the right to inspect and request a copy of medical information that may be used to make decisions about your care and portability of our records.  Usually, this includes medical and billing records including psychotherapy notes.  To inspect and copy medical information that may be used to make decisions about you, your must submit your request in writing.  If you request a copy of the information, 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 very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the agency will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

• Right to Amend    If you feel that medical 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 for as long as the information is kept by, or for, the agency.  To request an amendment, your request must be made in writing.  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 information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment

• Is not part of the medical information kept by or for the agency

• Is not part of the information which you would be permitted to inspect and copy

• Is accurate and complete

• 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.  To request this list or accounting of disclosures, you must submit your request in writing and state a time period that may not be longer than six years prior to your request.  The first accounting is free, but a fee will apply if more than one request is made in a 12-month period.

• Right to Request Restrictions    You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a treatment you had.  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 must make your request in writing.  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 Communication    You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. To request confidential communications, you must make your request in writing.

• 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.

CHANGES TO THIS NOTICE

We reserve the right to change 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 agency.  The notice will contain on the first page in the top center, the effective date.  In addition, each time you register at or are re-admitted to the agency for treatment or health care services, you will be offered a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the agency or with the Secretary of the Department of Health and Human Services.  All complaints must be in writing.  To file a complaint with the agency, contact the privacy officer.  We will investigate all complaints and you will not be penalized or discriminated against for filing a complaint.  If you wish to file a complaint with the Secretary of the Department of Health and Human Services, you may send the complaint to:

OTHER USES OF 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 the care that we provided to you.