The Ark Family Counseling Center
NOTICE OF PRIVACY PRACTICES
Effective September, 1 2007
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.
We are required by law to maintain the privacy of Consumer Health Information about you that identifies you. This may be information about health care services that we provide to you or payment for health care provided to you. It may be information about your past, present, or future health care condition. We are required by law to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices with regard to your PHI. We are legally bound to follow the terms of this Notice. In other words, we are only allowed to use and disclose health care information in the manner that we have described in this Notice.
USES AND DISCLOSURES OF CONSUMER HEALTH INFORMATION
WHAT IS CONSUMER HEALTH INFORMATION
Consumer health information is demographic and individually identifiable health information that will or may identify the patient and relates to the patient's past, present or future physical or mental health or condition and related health care services.
We use and disclose Consumer Health Information about you in order to provide treatment, to obtain payment for that treatment, to operate our business efficiently, or for other legally mandated or authorized purposes. The following lists, and the examples shown, are not exhaustive:
We may use or disclose your Consumer Health Information with health care providers who are involved with your health care. For example, information may be shared to determine the course of treatment that would work best for you.
We may use or disclose your Consumer Health Information to obtain payment for services we provide to you. Information may be shared with Mental Health Partners for billing/management services and any third party payers. Third party payers may include your insurance company, Medicaid, Wellcare, Peachcare, or Cempatico. Data released to any of the above mentioned parties may include the dates of service, type of service, diagnosis, name of service provider, and charges, and any available drug/alcohol information.
HEALTH CARE OPERATIONS
We may use or disclose Consumer Health Information in order to manage our programs, services, and activities. For example, we may use your Consumer Health Information to review the quality of services you receive.
Unless you give us a written authorization to do so, we cannot use or disclose your Consumer Health Information for any reason except for the treatment, payment or health care operations described in this Notice. If you give us an authorization to use your Consumer Health Information or to disclose it to anyone for other purposes, you may revoke such authorization at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.
PERSONS INVOLVED IN CARE
We may disclose Consumer Health Information about you to a relative, close personal friend, or any other person you identify if (1) that person is involved in your care, and (2) the information is relevant to your care. If the patient is a minor, except in limited circumstances, we may disclose Consumer Health Information about the minor to a parent, guardian, or other person responsible for the minor.
REQUIRED BY LAW
We may disclose your Consumer Health Information if in our reasonable judgment, there is an eminent danger to the health or safety of you or some individual.
ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
We may disclose Consumer Health Information to a government authority that is authorized by law to conduct an investigation or audit, if we reasonably believe that you may be a victim of abuse, neglect or domestic violence.
PUBLIC HEALTH ACTIVITIES
We may disclose Consumer Health Information about you for Public Health activities. For example, activities related to investigating exposure to communicable diseases, problems with medical products, or reporting child abuse and neglect.
HEALTH OVERSIGHT ACTIVITIES
We may disclose Consumer Health Information about you to a Health Oversight agency. For example, a government agency may request information from us while they are investigating possible insurance fraud.
We may disclose Consumer Health Information about you to a court or an officer of the court, such as an attorney. For example, we would disclose Consumer Health Information, about you to a court, if ordered by the judge to do so.
We may disclose Consumer Health Information for specific law enforcement purposes. For example, we may disclose limited Consumer Health Information in response to a law enforcement official’s request for such information, for the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
We may use or disclose Consumer Health Information for certain governmental functions. For example, we may disclose Consumer Health Information about you for national security and intelligence activities.
THREAT TO HEALTH OR SAFETY
We may disclose your Consumer Health Information to the extent necessary to avert a serious threat to your health or safety, or to the health or safety of others.
We may send you reminders for medical care or checkups.
YOUR PRIVACY RIGHTS
YOU HAVE RIGHTS WITH RESPECT TO HEALTH CARE INFORMATION ABOUT YOU
RIGHT TO INSPECT AND OBTAIN COPY
You have the right to inspect and obtain a copy of your Consumer Health Information that is contained in a “designated record set” for so long as we maintain the Consumer Health Information. Your request to inspect or obtain a copy of the records must be submitted in writing, signed and dated, to the Ark Family Counseling Center.
RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES
You have the right to request an accounting of certain disclosures of your Consumer Health Information by the Ark FCC. This right applies to disclosures for purposes other than treatment, payment or healthcare operations, and certain other activities, as described in this Privacy Notice. Accounting requests may not be made for periods of time in excess of six years.
RIGHT TO REQUEST RESTRICTIONS
You have the right to ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. The Ark FCC is not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your Consumer Health Information in violation of that restriction unless it is needed to provide emergency treatment.
RIGHT TO REQUEST ALTERNATIVE / CONFIDENTIAL COMMUNICATIONS
You have the right to request that we communicate with you about your health in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. Your request for confidential communications must be in writing, signed, and dated. We will accommodate all reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request.
RIGHT TO AMEND
You have the right to request an amendment of Consumer Health Information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment, and will provide you with an explanation of our reason for doing so. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your Consumer Health Information, please contact our Privacy Officer. Requests for amendments must be in writing.
RIGHT TO A 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 at any of our facilities or by calling the Ark Family Counseling Center Privacy Office at (770) 593-0913. You may also view this
Notice at our Web site, www.thearkfcc.com.
CHANGES TO THIS NOTICE
We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all health care information that we maintain. If we make changes to the Notice, we will (1) post the new Notice in our waiting area, and (2) have copies of the new Notice available upon request. The effective date of the Notice is on the first page in the top right corner.
QUESTIONS / COMPLAINTS
If you have questions regarding your privacy rights, please contact the Ark Family Counseling Center Privacy Officer at (770) 593-0913. If you believe your privacy rights have been violated, you may file a complaint by contacting the Ark Family Counseling Center Privacy Officer (770) 593-0913, via email at firstname.lastname@example.org, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:
Office of Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center
61 Forsyth St., S.W.
Atlanta, GA 30303-8909
(404) 562-7886 (phone)
(404) 562-7881 (fax)
(404) 331-2867 (TDD)
FOR MORE INFORMATION
If you have any questions about this Notice, or need more information, need forms, or want to file a complaint, contact the following Privacy Officer:
The Ark Family Counseling Center
4256 Clausell Court, Suite 300-B
Decatur, GA 30035
Attn: Privacy Officer