FAMILY RESOURCE CENTERS NOTICE O

EFFECTIVE: April 14, 2003

THIS NOTICE DESCRIBES HOW TREATMENT 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 Agency Privacy Officer

WHO WILL FOLLOW THE REQUIREMENTS OF THIS NOTICE?

This notice describes Family Resource Centers’ (FRC) practices and those of:

· Any health care professional permitted to enter information into your agency chart.

· All departments and programs of FRC.

· Any member of a volunteer group we allow to help you while under FRC’s care.

· All employees, staff, student interns, and other agency workers.

· All of the following business associates of FRC agree with the terms of this notice. In addition, as business associates we may share treatment information with each other for the purpose of treatment, payment, or agency operations.

1. Mental Health & Recovery Services Board of Allen, Auglaize, & Hardin Counties

2. Hancock County Board of Alcohol, Drug Addiction & Mental Health Services

3. Behavioral Health Generations

4. Treatment Transcription ist

5. Robert Leonard Law Offices, LLC

6. Steyer, Huber & Associates, Inc.

7. Management Information Systems vendors (computer system repair and service)

OUR PLEDGE REGARDING YOUR TREATMENT INFORMATION:

We understand that treatment information about you and your health is personal. We are committed to protecting treatment information about you. We create a record of the care and services you receive at FRC. We need this information to provide you with quality care and to follow certain legal requirements. This notice applies to all the records of your care created by FRC, whether made be agency employees (example, counselors, case managers) or staff under contract to the agency (example, psychiatrist, clinicians).

This notice will tell you about the ways in which we may use and share treatment information about you. We also describe your rights and certain duties we have regarding the use and sharing of your treatment information. We are required by law to:

· Make sure that treatment information that identifies you is kept private;

· Give you notice of our legal duties and privacy practices with respect to treatment information about you;

· Follow the terms of the privacy notice that is currently in effect.

HOW MAY WE USE AND SHARE TREATMENT INFORMATION ABOUT YOU?

The following categories describe different ways that we may use and share treatment information. For each category we will explain what we mean and try to give some examples. Not every use or sharing situation in a category will be listed. However, all of the ways we are permitted to use and share your health information will fall within one of the categories.

· For Treatment • For Payment

· For Health Care Operations • Appointment Reminders

· Treatment Alternatives

· Individuals Involved in Your Care or Responsible for Payment of Your Care

SPECIAL SITUATIONS

· Military and Veterans

· Public Health Risks

· Lawsuits and Disputes

· Coroners, Medical Examiners and Funeral Directors

· National Security and Intelligence Activities

· Health-Related Benefits and Services

· Required By Law

· To Prevent a Serious Threat to Health or Safety

· Workers’ Compensation

· Health Oversight Activities

· Law Enforcement

· Protective Services for the President and Others

· Inmates

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

· Right to Inspect and Copy You have the right to inspect and copy treatment information that may be used to make decisions about your care. Usually, this includes treatment and billing records including counseling notes. To inspect and/or copy your treatment information you must make a request in writing using the Client Request to Inspect and Copy Protected Health Information form (FRC 018). Submit the request form to the Site Secretary. If you request a copy of the information, we will charge a fee at the time of your request, for the costs of copying, mailing, or other supplies associated with your requests. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your treatment information, you may request that the denial be reviewed. A licensed health care professional chosen by FRC will review your request and the denial. The person reviewing your request will not be the person who initially denied your request. We will agree with the outcome of the review.

· Right to Amend If you feel that treatment information we have about you is incorrect or incomplete, you may ask us to correct the information. To request a change, your request must be made in writing, using the Client Request to Amend Protected Health Information (FRC 019) form and turned into the Site Secretary who shall submit your request to the Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to change information that:

1. Was not created by us, unless the person or agency that created the information is no longer available to make the change;

3. Is not part of the information which you would be permitted to inspect and copy; or

· Right to an Accounting of Disclosures You have the right to request an “accounting of disclosures”. This is a list of the treatment information about you that FRC has used or shared with others. To obtain this list, you must turn in a written request using the Client Request for an Accounting of Disclosures (FRC 020) to Clinical Records. Your request must state a time period that may not be longer than 6 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 will charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or change your request at that time before any costs are charged.

· Right to Request Restrictions You have the right to request a restriction or limitation on the treatment information we use or share about you for treatment, payment, or health care operations. You also have the right to request a limit on the treatment information we share about you to someone who is involved in your care or the payment for your health care. We are not required to agree to your request. If we do agree, we will honor your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to the Site Secretary using the Client Request for Restrictions on Use/Disclosure of Protected Health Information (PHI) form (FRC 021). The Site Secretary shall forward your request to the Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, sharing of information with others or both; and (3) to whom you want the limits to apply, for example, you don’t want information shared with your spouse.

· Right to Request Confidential Communications You have the right to request that we communicate with you about treatment 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 must make your request to the Privacy Officer. We will not ask you the reason for your request. We will agree to all reasonable requests. Your request must state how and where you wish to be contacted.

· Right to a Paper Copy of this Notice The copy of this Privacy Notice included in this Client Handbook shall serve as your paper copy of this notice.

We have the right to change this notice. We also have the right to make the updated or changed notice effective for treatment 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 FRC waiting areas. The notice will contain on the first page, the effective date. In addition, each time you are readmitted to FRC for treatment or other health care services, you will be offered a copy of the current notice. You may request a copy of the entire Privacy Notice at anytime.

If you believe your privacy rights have been violated, you may file a complaint with FRC or with the Secretary of the Department of Health and Human Services. To file a complaint with FRC, contact the Privacy Officer (419-222-1168). All complaints must be in writing.

Other uses of treatment information not covered by this notice or the laws that apply to FRC will be made only with your written permission. If you provide us with permission to use or share treatment information about you, for purposes other than treatment, payment, or health care operations, you may cancel that permission in writing at any time. If you cancel your permission, we will no longer use or share treatment information about you for the reasons covered by your written permission. You need to understand that we are unable to take back any sharing of information that we have already made with your permission. We are required to keep our records of the care we provided to you.