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. This notice takes effect on April 14, 2003 and remains in effect until we replace it.
Our pledge regarding your health information.
Protected health information (PHI) - PHI is information we obtain and create in providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnosis and treatment. It also includes billing documents for those services.
Treatment: To appropriately determine approvals or denials of your medical treatment. For example, your PHI will shared among members of our treatment team.
Payment: We may use or disclose your PHI in order to bill and collect payment for your health care services. For example, your health care provider may send claims for payment to Medicare for medical services provided to you, if appropriate.
Health Care Operations: We may use or disclose your PHI, as needed, in order to improve the quality of your care. For example, members of the treatment team may share PHI to assess the care and outcomes in your case.
Public Health Activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics or the result of public health surveillance, investigations or interventions. ]
Victims of Abuse, Neglect or Domestic Violence: We may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect or domestic violence.
Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the behavioral health care system, government programs and compliance with civil rights laws.
When Required by Law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, for a crime committed on the premises, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
Uses and Disclosures Requiring Authorization: We are required to have your written authorization for the following. Authorizations can be revoked at any time to stop future uses/disclosures except to extent that we have already undertaken in action based upon your authorization.
- Substance Abuse Health Information All PHI regarding substance abuse is to be kept strictly confidential and released only in conformance with the requirements of federal law (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3) and regulation (42 C.F.R. part 2). Disclosure of any medical information referencing alcohol or substance abuse may be only made with your written authorization. A general authorization for the release of other information is not sufficient for purpose.
- HIV Information - All PHI regarding HIV is kept strictly confidential and released only in conformance with the requirements of state law. Disclosure of any medical information referencing HIV status may only be made with your written authorization. A general authorization for the release of medical or other information is not sufficient for this purpose.
The law requires us to:
- Keep your health information private.
- Give you this Notice describing our legal duties, privacy practices and your rights regarding your health information.
- Follow the terms of the Notice currently in effect.
We have the right to:
- Change our privacy practices and to apply the revised practices to health information about you that we already have.
- Post any revisions to our privacy practices in a revised Notice that will be posted prominently in our facility.
How We May Use and Disclose Health Information About You:
We will not use or disclose your health information without your authorization, except in the following situations:
Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associates so they can perform the job we have asked them to do. However, we require business associates to take precautions to protect your health information.
Notification of Family: We may use or disclose information to relay or assist in relaying your location and general condition to a family member, personal representative or other person responsible for your care.
Communication With Family: We may disclose to a family member, other relative, close friend or any other person you identify, health information relevant to that person's involvement in your care.
Research: Consistent with applicable law, we may disclose information to researchers when 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 health information.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events, product defects or post-marketing surveillance information to enable product recalls, repairs or replacement.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse and neglect.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect or domestic violence.
Health Oversight: In order to oversee the healthcare system, government benefits programs, entities subject to governmental regulation and civil rights laws for which health information is necessary to determine compliance, we may disclose your health information for oversight activities authorized by law, such as audits and civil, administrative or criminal investigations.
Court Proceedings: We may disclose your health information in response to requests made during judicial and administrative proceedings, such as court orders or subpoenas.
Law Enforcement: Under certain circumstances, we may disclose your health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises and crimes in emergencies.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Threats to Public Health or Safety: We may disclose or use health information when it is our good faith belief, consistent with ethical and legal standards, that it is necessary to prevent or lessen a serious and imminent threat or is necessary to identify or apprehend an individual.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
Other Uses: We may also use and disclose your personal health information for the following purposes:
- To contact you to remind you of an appointment for treatment;
- To describe or recommend treatment alternatives to you;
- To furnish information about health-related benefits and services that may be of interest to you
Prohibition on Other Uses or Disclosures: We may not make any other use or disclosure of your personal health information without your written authorization. Once given, you may revoke the authorization by writing to the contact person listed below. Understandably, we are unable to take back any disclosure we have already made with your permission.
Individual Rights: You have many rights concerning the confidentiality of your health information. You have the right:
- To request restrictions on the health information we may use and disclose for treatment, payment and health care options. We are not required to agree to these requests.
- To request restrictions; please send a written request to the address listed.
- To request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your health information to you by different means or at different locations must be made in writing to the contact person listed at the end of the notice.
- To look at or copy your health information. You must submit your request in writing to the address listed. If you request a copy of your health information, we may charge you a fee for the cost of the copying, mailing or other supplies. In certain circumstances, we may deny your request to inspect or copy your health information. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional will then review your request. We will comply with the outcome of the review.
- To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address listed below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if: We did not create the information, unless the person that created the information is no longer available to make the amendment, the information is not part of the health information kept by or for us, is not part of the information you would be permitted to inspect or copy, or is accurate and complete.
- To receive a list of all the times we, or our business associates shared your health information for purposes other than treatment, payment, and health care operations and other specified exceptions, you must submit a request in writing to the address listed below. Not all health information is subject to this request. Your request must state a time period, no longer than six (6) years and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper). The first accounting you request within a 12-month period is free. For additional accounting, we may charge you the cost of providing the accounting. We will notify you of the cost and you may choose to withdraw or modify your request before charges are incurred.
- To receive a paper copy of this Notice, even if you have agreed to receive the Notice electronically, you must make a request in writing to the Privacy Officer listed below. You may also obtain a copy of this notice at our website.
Complaints: If you believe that your privacy rights have been violated, a complaint may be made to our Privacy officer at the address listed below.
You may also submit a complaint to the Secretary of the Department of Health and Human Services at The Office of Civil Rights, The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, 1-202-619-0257 or toll free 1-877-696-6775. We will not retaliate against you for filing a complaint.
Contact Person: Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Medical Business Office, Privacy Officer, P.O. BOX 44308, PHOENIX, AZ 85064