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SOUTHEASTERN REGIONAL MENTAL HEALTH, DEVELOPMENTAL DISABILITIES,
AND SUBSTANCE ABUSE SERVICES NOTICE OF PRIVACY PRACTICES
Effective
Date: 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.
Southeastern
Regional Mental Health, Developmental Disabilities, and Substance
Abuse Services (Southeastern Regional MH/DD/SAS or Area Program)
works with a network of qualified providers and provides many
types of services, such as screenings, assessments, and case
management. Southeastern Regional MH/DD/SAS staff must collect
information about you to provide these services. Southeastern
Regional MH/DD/SAS knows that information collected about
you and your health is private. Our Area Program is required
to protect this information by Federal and State law. This
information is called "protected health information" (PHI)
whether oral, written, or in electronic format.
The
Notice of Privacy Practices tells you how Southeastern Regional
MH/DD/SAS may use or disclose (tell others) information about
you and that as required by law only the minimum necessary
information will be disclosed. Not all situations are described.
Southeastern Regional MH/DD/SAS is required to give you a
notice of our privacy practices for the information collected
and kept about you. The Area Program is required to follow
the terms of the notice currently in effect. Southeastern
Regional MH/DD/SAS reserves the right to revise the terms
of this notice.
Southeastern
Regional MH/DD/SAS May Use and Disclose Information Without
Your Authorization
Southeastern
Regional Mental Health, Developmental Disabilities and Substance
Abuse Services will maintain sufficient records to justify
thorough and appropriate treatment. The information you provide
us is confidential and release or disclosure of any identifiable
information to any individual or agency is prohibited except
under the following ethical and legal conditions:
- You
or your legal representative has signed a valid authorization
for release of information to a third party. (INFORMED CONSENT)
- You
are seeking treatment at another facility within the N.C.
Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services and it has been determined to be
in your best interest to disclose information to the facility
where you are requesting services. (This excludes consumers
receiving substance abuse treatment).
- Information
may be shared with a service provider or agency that contracts
with Southeastern Regional Mental Health Developmental Disabilities
and Substance Abuse Services (if deemed to be in the best
interest of the consumer). This excludes consumers receiving
substance abuse treatment.
- In
the interest of public safety. (It is determined by a clinical
staff member that you present a danger to yourself or others).
- In
response to a court order and/or subpoena.
- In
response to a medical emergency, disclosure may be made
to medical personnel.
- State
and federal laws require reporting of child abuse, disabled
adult abuse, gunshot/knife wounds, and communicable diseases.
- Crimes
committed at the program. Crimes against any employee of
the program, and any threat to commit such a crime.
- In
the investigation of life-threatening threats to an elected
official.
- Disclosure
may be made to qualified personnel for research, audit,
or program evaluation. When information is disclosed based
on the limited circumstances of disclosures, documentation
to support this action shall be recorded on the Accounting
of Release/Disclosure Form in the service record. Information
disclosed without a signed consent indicates, "disclosed"
on the form. As required by 164.514 of the Federal Regulations
45 C.F.R Part 164, we will limit the protected health information
disclosed to the minimum amount necessary to achieve the
purpose for which the disclosure is sought.
Other
Uses and Disclosures Require Your Written Authorization
For
other situations, Southeastern Regional MH/DD/SAS will ask
for your written authorization before using or disclosing
information. You may cancel/revoke this authorization at any
time in writing and forward it to your clinician or the supervisor.
Southeastern Regional MH/DD/SAS cannot take back any uses
or disclosures already made with your authorization. For
Treatment and Payment Purposes and for Health Care Operations
federal regulations permit disclosure without your authorization
(45 C.F.R. Part 164). However, other laws require consents
in writing. North Carolina G.S. 122C-53(a) states that
a MH/DD/SA facility may disclose confidential information
if the client or his legally responsible person consents in
writing to the release of information to a specified person.
The release is valid for a specified length of time and is
subject to revocation. Example of Treatment Purposes:
You are receiving treatment and you want a copy of your record
to go to your medical doctor. Example of Payment Purposes:
Your insurance carrier, Medicare, or Medicaid has required
us to release diagnostic and treatment records to assist in
processing payment. Example of Health Care Operations,
Southeastern Regional MH/DD/SAS may use or disclose information
in order to manage its programs and activities. For example,
this information may be used in Utilization Management to
review the quality of service you are receiving.
As
required by 164.514 of the Federal Regulations 45 C.F.R Part
164, we will limit the protected health information disclosed
to the amount minimally necessary to achieve the purpose for
which the disclosure is sought.
Other
Laws Protect Health Information.
Southeastern
Regional MH/DD/SAS also follows other laws for the use and
disclosure of information about you. (G.S. 122-C; 42 CFR Part
2; 45 CFR Parts 160 and 164; N.C. Division of MH/DD/SA Services
Confidentiality Rules APSM 45-1)
Your
Privacy Rights
When
information is maintained by Southeastern Regional MH/DD/SAS
as a mental health agency, other State and Federal laws govern
the mental health records.
Right
to Request Restrictions on Uses and Disclosures. You have
the right to request that we limit the use and disclosure
of health care information about you for treatment, payment,
and health operations. Southeastern Regional MH/DD/SAS is
not required to agree to your request. If we agree to your
request, we must follow your restrictions (except if the information
is necessary for emergency treatment). You may cancel the
restrictions at any time. In addition, we may cancel a restriction
at any time as long as we notify you of the cancellation and
continue to apply the restriction to information collected
before the cancellation.
Right
to Request An Alternative Method of Contact. You have
the right to be contacted at a different location or by a
different method. For example, you may prefer to have all
written information mailed to your work address rather than
your home address. We will agree to any reasonable request
for alternative methods of contact. If you would like to request
an alternative method of contact, you must provide us with
a request in writing. You may write us a letter or fill out
an Alternative Contact Request Form. Alternative Contact Request
Forms are available from our Privacy Officer located at the
Area Program.
Right
to See and Get Copies of Your Records. In most cases,
you have the right to look at or get copies of your records.
You must make the request in writing to your clinician using
the Access to Record Form. The Area Program will act on this
request no later than thirty (30) days after receipt of the
request. You may be charged a fee for the cost of copying
your records.
Right
to Request to Correct or Update Your Records. You may
ask Southeastern Regional MH/DD/SAS to change or add missing
information to your records if you think there is a mistake.
You must make the request in writing to your clinician using
the Amendment Request Form and provide a reason for your request.
The Area Program must act on this request no later than sixty
(60) days after receipt of the request.
Right
to Get a List of Disclosures. You have the right to ask
Southeastern Regional MH/DD/SAS for a list of disclosures
made about you after April 14, 2003. You must make the request
in writing. This list will not include the times that information
was disclosed for treatment, payment, or health care operations.
The list will not include information provided directly to
you or your family, or information that was sent with your
authorization.
Right
to Receive a Copy of the Notice of Privacy and Any Revisions
Thereafter. You have the right to receive a copy of the
notice of privacy and any revisions made thereafter. The terms
of this notice may be changed in the future, and these changes
will be posted in the waiting room of the agency, and/or posted
on the agency website (located at www.srmhc.org). You may
also request a copy of the Notice of Privacy Practices by
contacting the Privacy Officer at (910)-738-5261. If you have
any questions or would like additional information you may
contact the Privacy Officer.
YOU
MAY FILE A COMPLAINT/GRIEVANCE ABOUT OUR PRIVACY PRACTICES
If
you believe that your privacy rights have been violated or
if you are dissatisfied with our privacy policies and procedures,
you may file a complaint either with us or with the federal
government. We will not take any action against you or change
our treatment of you in any way if you file a complaint/grievance.
If
you have a complaint/grievance concerning a violation of your
privacy rights you may contact your clinician or go directly
to the supervisor as outlined in the Client Grievance Procedure.
You also have the right to contact the Governor's Advocacy
Council for Person's with Disabilities at 1-800-821-6922.
To
file a complaint with the federal government, you may contact
the Office of Civil Rights for assistance. North Carolina
residents' contact: 1-404-562-7886 or 1-404-562-7881 (Fax)
Region
IV/Office for Civil Rights
US Department of Health and Human Services
Atlanta Federal Center Suite 3B70/ 61 Forsyth Street, SW.
Atlanta, Georgia 30303-8909
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