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NEW DESTINY
TREATMENT CENTER
NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003
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.
If you have questions about this notice, please contact the NDTC Privacy Officer.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our office except when the release is required or authorized by law or regulation.
ACKNOWLEDGEMENT
OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgement of receipt of this notice.
Our intent is to make you aware of the possible uses and disclosures of your
protected health information and your privacy rights. The delivery of your
health care services will in no way be conditioned upon your signed acknowledgment.
If you decline to provide a signed acknowledgement, we will continue to provide
your treatment, and will use and disclose your protected health information
for treatment, payment, and health care operations when necessary.
OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION
“Protected health information” is individually identifiable health
information. This information includes demographics, for example, name, age,
address, social security number, and relates to your past, present, or future
physical or mental health or condition and related health care services. The
NDTC is required by law to do the following:
• Make sure that your protected health information is kept private.
• Give you this notice of our legal duties and privacy practices related
to the use and
disclosure of your protected health information.
• Follow the terms of the notice currently in effect.
• Communicate any changes in the notice to you.
We reserve the right
to change this notice. Its effective date is at the top of the first page
and at the bottom of the last page. We reserve the right to make the revised
or changed notice effective for health information we already have about you
as well as any information we receive in the future. This notice is yours.
You may obtain a Notice of Privacy Practices by contacting the NDTC Privacy
Officer or Office Manager and requesting a copy.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Required Uses and Disclosure
By law, we must disclose your health information to you unless it has been
determined by a competent medical authority that it would be harmful to you.
We must also disclose health information to the Secretary of the Department
of Health and Human Services (DHHS) for investigations or determinations of
our compliance with laws on the protection of your health information.
Without Your Consent
Without your consent, we may use or disclose your personal health information
in order to provide you with services and the treatment you require or request,
or to collect payment for those services, and to conduct other related health
care operations otherwise permitted or required by law. Also, we are permitted
to disclose your personal health information within and among our workforce
in order to accomplish these same purposes. For uses beyond that, we must
have your written authorization. We also must have your written consent for
any disclosure of your drug and alcohol records (42 C.F.R.). However, even
with your permission, we are still required to limit such uses or disclosures
to the minimal amount of personal health information that is reasonably required
to provide those services or complete those activities.
Treatment
We will use and disclose your protected health information to provide, coordinate,
or manage your health care and any related services. This includes the coordination
or management of your health care with a third party. For example, we would
disclose your protected health information, as necessary, to another physician
or health care provider (for example, a specialist, pharmacist, or laboratory)
who, at the request of your physician, becomes involved in your care by providing
assistance with your health care diagnosis or treatment. This includes pharmacists
who may be provided information on other drugs you have been prescribed to
identify potential interactions.
In emergencies, we will use and disclose your protected health information
to provide the treatment you require.
Payment
Your protected health information will be used, as needed, to obtain payment
for your health care services. Examples of payment activities include billing
and collection activities to the Ohio Medicaid Program, and related data processing,
utilization review activities (reviewing health care information and bills
to make sure that you get quality care and that all laws providing and paying
for your health care are being followed), and reviewing services provided
to you for medical necessity. This may include certain activities the NDTC
might undertake in determining eligibility or coverage for benefits.
Health Care Operations
We may use or disclose, as needed, your protected health information to support
the daily activities related to health care. These activities include, but
are not limited to, quality assessment activities, investigations, oversight
or staff performance reviews, training of health care professionals such as
medical/nursing students and counselors, communications about a product or
service, development of clinical guidelines, contacting patients/clients with
information about treatment alternatives or communications in connection with
case management or care coordination, legal services, auditing functions.
We may call you by name in the waiting room when your physician or other health
care professional is ready to see you. We may use or disclose your protected
health information, as necessary, to contact you to remind you of an appointment.
We will share your protected health information with third-party “business
associates” who perform various activities (for example, clearinghouses
who transmit electronic data for billing purposes). The business associates
will also be required to protect your health information.
Required by Law
We may use or disclose your protected health information if law or regulation
requires the use or disclosure. Examples of instances in which we are required
to disclose your personal health information include the following.
Public Health
We may disclose your protected health information to a public health authority
that is permitted by law to collect or receive the information. The disclosure
may be necessary to do the following:
• Prevent or control disease, injury, or disability.
• Report births and deaths.
• Report child abuse or neglect.
• Report reactions to medications or problems with products.
• Notify a person who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition.
• Notify the appropriate government authority if we believe a patient/client
has been the victim of abuse, neglect, or domestic violence.
Communicable Diseases
We may disclose your protected health information, if authorized by law, to
a person who might have been exposed to a communicable disease or might otherwise
be at risk of contacting or spreading the disease or condition.
Health Oversight
We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections.
These health oversight agencies might include government agencies that oversee
the health care system, government benefit programs, other government regulatory
programs, and civil rights laws.
Food and Drug Administration
We may disclose your protected health
information to a person or company required by the Food and Drug Administration
to do the following:
• Report adverse events, product defects, or problems and biologic product
deviations.
• Track products.
• Enable product recalls.
• Make repairs or replacements.
• Conduct post-marketing surveillance as required.
Legal Proceedings
We may disclose protected health information during any judicial or administrative
proceeding in response to a court order or administrative tribunal, warrant,
subpoena, discovery request, or other lawful process.
Law Enforcement
We may disclose protected health information for law enforcement purposes,
including the following:
• Responses to legal proceedings.
• Information requests for identification and location of a suspect,
fugitive, material witness, or missing person.
• Circumstances pertaining to victims of a crime.
• Deaths suspected from criminal conduct.
• Crimes occurring at the NDTC site.
• Medical emergencies (not on the NDTC premises) believed to result
from criminal conduct.
Coroners, Funeral Directors, and Organ Donations
We may disclose protected health information to coroners or medical examiners
for identification to determine the cause of death or for the performance
of other duties authorized by law. We may also disclose protected health information
to funeral directors as authorized by law. Protected health information may
be used and disclosed for cadaveric organ, eye, or tissue donations.
Research
We may disclose your protected health information to researchers when authorized
by law, for example, if their research has been approved by an institutional
review board that has reviewed the research proposal and established protocols
to ensure the privacy of your protected health information.
Criminal Activity
Under applicable Federal and state laws, we may disclose your protected health
information if we believe that its use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety of a person
or the public. We may also disclose protected health information if it is
necessary for law enforcement authorities to identify or apprehend an individual.
Military and Veterans Activities
When When the appropriate conditions apply, we may use or disclose protected
health information of individuals in determining fitness for duty, for determination
by the Department of Veterans Affairs (VA) of your eligibility for benefits,
or to a foreign military authority if you are a member of that foreign military
service. We may also disclose protected health information to authorized Federal
officials for conducting national security and intelligence activities including
protective services to the President or others.
Workers’ Compensation
We may disclose your protected health information to comply with workers’
compensation laws and other similar legally established programs.
Inmates
We may use or disclose your protected health information if you are an inmate
of a correctional facility, and the NDTC created or received your protected
health information while providing care to you. This disclosure would be necessary
for the institution to provide you with health care, and for your health and
safety or the health and safety of others.
Parental Access
Some state laws concerning minors permit or require disclosure of protected
health information to parents, guardians, and persons acting in a similar
legal status. We will act consistently with the law of the state where treatment
is provided and will make disclosures following such laws.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRING YOUR
PERMISSION
In some circumstances, you have the opportunity to agree or object to the
use of disclosure of all or part of your protected health information. Following
are examples in which your agreement or objection is required.
Patient/Client Directories
Unless you object, we will use and disclose in our NDTC directory, your name,
the location at which you are receiving care, your condition (in general terms),
and your religious affiliation. All of this information, except religious
affiliation, will be disclosed to people who ask for you by name. Only members
of the clergy will be told your religious affiliation.
Individuals Involved in Your Health Care
Unless you object, we may disclose to a member of your family, a relative,
a close friend, or any other person you identify, your protected health information
that directly relates to that person’s involvement in your health care.
We may also give information to someone who helps pay for your care. Additionally
we may use or disclose protected health information to notify or assist in
notifying a family member, personal representative, or any other person who
is responsible for your care, of your location, general condition, or death.
Finally, we may use or disclose your protected health information to an authorized
public or private entity to assist in disaster relief efforts and coordinate
uses and disclosures to family or other individuals involved in your health
care.
USES AND DISCLOSURES OF
PERSONAL HEALTH INFORMATION FROM ALCOHOL AND OTHER DRUG RECORDS NOT REQUIRING
{CONSENT OR} AUTHORIZATION:
Generally, the program may not say to a person outside the program that a
patient attends the program, or disclose any information identifying a patient
as an alcohol or drug abuser, without consent or authorization, except for
the following circumstances:
When required by law: We may disclose personal health information
when a law requires that we report information about suspected child abuse
and neglect, or when a crime has been committed on the program premises or
against program personnel, or in response to a court order.
Relating to decedents: We may disclose personal health information
relating to an individual’s death if state or federal law requires the
information for collection of vital statistics or inquiry into cause of death.
For research, audit or evaluation purposes, and medical emergencies:
In certain circumstances, we may disclose personal health information for
research, audit or evaluation purposes, and medical emergencies.
To avert threat to health or safety: In order to avoid a
serious threat to health or safety, we may disclose PHI to law enforcement
when a threat is made to commit a crime on the program premises or against
program personnel.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You may exercise the following rights by submitting a written request or electronic
message to the NDTC Privacy Officer. Please be aware that the NDTC might deny
your request; however, you may seek a review of the denial.
Right to Inspect and Copy
You may inspect and obtain a copy of your protected health information that
is contained in a “designated record set” for as long as we maintain
the protected health information. A designated record set contains medical
and billing records and any other records that the NDTC uses for making decisions
about you. We must provide you with access to your personal health information
in the form or format requested by you, if it is readily producible in such
form or format, or, if not, in a readable hard copy form or such other form
or format. We may provide you with a summary of the personal health information
or may provide an explanation of the personal health information to which
access has been provided. If you request a copy of your personal health information
or agree to a summary or explanation of such information, we may charge a
reasonable cost-based fee for copying, postage, if you request a mailing,
and the costs of preparing an explanation or summary as agreed upon in advance.
This right does not include inspection and copying the following records:
information compiled in reasonable anticipation of, or use in civil, criminal,
or administrative action or proceeding; and protected health information that
is subject to law that prohibits access to protected health information.
Right to Request
Restrictions
You may ask us not to use or disclose any part of your protected health information
for treatment, payment, or health care operations. Your request must be made
in writing to the NDTC Privacy Officer. In your request, you must tell us
(1) what information you want restricted; (2) whether you want to restrict
our use, disclosure, or both; (3) to whom you want the restriction to apply,
for example, disclosures to your spouse; and (4) an expiration date.
If the NDTC believes that the restriction is not in the best interest of either
party, or the NDTC cannot reasonably accommodate the request, the NDTC is
not required to agree. If the restriction is mutually agreed upon, we will
not use or disclose your protected health information in violation of that
restriction, unless it is needed to provide emergency treatment. You may revoke
a previously agreed upon restriction, at any time, in writing.
Right to Request Confidential Communications
You may request that we communicate with you using alternative means or at
an alternative location. We will not ask you the reason for your request.
We will accommodate reasonable requests, when possible.
Right to Request Amendment
If you believe that the information we have about you is incorrect or incomplete,
you may request an amendment to your protected health information as long
as we maintain this information. We have the right to deny your request for
amendment, if: (1) we determine that the information or record that is the
subject of the request was not created by us, unless you provide a reasonable
basis to believe that the originator of the information is no longer available
to act on the requested amendment; (2) the information is not part of your
designated record set maintained by us; (3) the information is prohibited
from inspection by law; or (4) the information is accurate and complete. We
may require that you submit written requests and provide a reason to support
the requested amendment. If we deny your request, we will provide you with
a written denial stating the basis of the denial, your right to submit a written
statement disagreeing with the denial and a description of how you may file
a complaint.
Right to an Accounting of Disclosures
You may request that we provide you with an accounting of the disclosures
we have made of your protected health information. This right applies to disclosures
made for purposes other than treatment, payment, or health care operations
as described in this Notice of Privacy Practices. The disclosure must have
been made after April 14, 2003, and no more than 6 years from the date of
request. This right excludes disclosures made to you, for a patient/client
directory, to family members or friends involved in your care, or for notification.
The right to receive this information is subject to additional exceptions,
restrictions, and limitations as described earlier in this notice.
Right to Obtain a Copy of this Notice
You may obtain a paper copy of this notice from the NDTC and/or an electronic
copy by email upon request.
FEDERAL PRIVACY LAWS
This NDTC Notice of Privacy Practices is provided to you as a requirement
of the Health Insurance Portability and Accountability Act (HIPAA). There
are several other privacy laws that also apply including the Freedom of Information
Act, the Privacy Act, and the Alcohol, Drug Abuse, and Mental Health Administration
Reorganization Act. See 42 U.S.C., 290 DD-3 and 42 U.S.C. 290 EE-3 for federal
laws and 42 CFR Part 2 for federal regulations. These laws have not been superseded
and have been taken into consideration in developing our policies and this
notice of how we will use and disclose your protected health information.
COMPLAINTS
If you believe these privacy rights have been violated, you may file a written
complaint with the NDTC Privacy Officer, 6694 Taylor Rd., Clinton, OH 44216,
or with the Secretary of the U.S. Department of Health and Human Services
at
200 Independence Avenue, SW, Washington D.C. 20201. A complaint must be received
by us or filed with the Secretary of DHHS within 180 days of when you knew
or should have known that the act or omission complained of occurred. No
retaliation
will occur against you for filing a complaint.
CONTACT INFORMATION
You may contact the NDTC Privacy Officer for further information about the
complaint process, or for further explanation of this document.
This notice is effective in its entirety as of April 14, 2003.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
I have received a copy of the New Destiny Treatment Center Notice of Privacy
Practices.
_______________________________
Patient/Client Signature
____________________________
Date
____________________________
Signature of Witness
© 2005 New Destiny Treatment Center, a non-profit organization.
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