NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU AND YOUR TREATMENT MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
CLIENT NAME is required by law to maintain the privacy and confidentiality of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. Please also respect the privacy of others you encounter in treatment.
CLIENT NAME collects health information about you and stores it in an electronic health record. This is your medical record. The medical record is the property of CLIENT NAME, but the information in the medical record belongs to you. The Health Insurance Portability and Accountability Act (HIPAA) requires CLIENT NAME to maintain the privacy of your medical record. HIPAA generally requires that any uses or disclosures of information in your medical record be limited to the minimum necessary to the purposes of the uses or disclosures. HIPAA also provides you certain rights with respect to the information in your medical record which are described below.
Information relating to your treatment at CLIENT NAME is protected by federal regulations specific to drug and alcohol treatment, which are known as 42 CFR Part 2. These regulations protect the confidentiality of information relating to the identity, diagnosis, prognosis, or treatment of any patient in a drug or alcohol treatment program. CLIENT NAME may not disclose records relating to your treatment without your written consent, except in narrowly limited circumstances. Under 42 CFR Part 2, the terms of a written consent to disclose information must specify the scope and types of information to be disclosed, the parties to whom the information may be disclosed, the purpose of the disclosure and the timeframe of the consent. You may revoke a consent to disclose information relating to drug and alcohol verbally or in writing at any time.
CLIENT NAME may ask for your written consent to disclose treatment information for certain purposes, including releasing treatment information to or obtaining information from your other medical providers, obtaining payment from insurance or other payors, contacting your family either for treatment purposes or in the case of a medical or other emergency. CLIENT NAME will not disclose your treatment information for these purposes without your consent.
CLIENT NAME may disclose treatment information without your written consent under certain narrow circumstances as permitted by 42 CFR Part 2. For treatment purposes, CLIENT NAME is permitted to use and disclose treatment information internally and to entities with which it shares administrative control. CLIENT NAME is permitted to share treatment information as necessary with qualified service organizations that agree to maintain the confidentiality of the information. CLIENT NAME also may disclose treatment information to outside auditors, regulatory agencies, and evaluators and for certain research purposes. CLIENT NAME may disclose treatment information without your written consent when necessary in a life-threatening medical emergency and may disclose to report a crime on the premises or againstCLIENT NAME personnel. CLIENT NAME also may disclose patient information without consent where the state mandates child abuse and neglect reporting; when cause of death is being reported; or when required by a valid court order that contains specific required findings. CLIENT NAME may contact you to share information about CLIENT NAME treatment services or to send you reminder notices of future appointments for your treatment.
- Your Health Information Rights
In addition to protecting privacy and confidentiality, HIPAA and 42 CFR Part 2 afford you the following rights with respect to your medical record and drug or alcohol treatment information:
- You have the right to a paper copy of this written notice of CLIENT NAME privacy practices. 2. You have a right to request a copy of your treatment record or to receive
- your health information through a reasonable alternative means or at an alternative location. CLIENT NAME requires that all such requests be put in writing. A reasonable fee will be charged for copying your health information.
- You have a right to request that CLIENT NAME amend health information that is incorrect or incomplete. If CLIENT NAMEdetermines not to amend the health information, it will provide you with an explanation of the reason for the denial and your rights to disagree with the denial.
- You have a right to request restrictions on otherwise permitted uses and disclosures of your health information. CLIENT NAME is not obligated to comply with such requests.
- You may request that we provide you with a written accounting of all disclosures made by us during a specific time period (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our facility. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made with your written consent for reasons of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.
- Changes to this Notice of Privacy Practices
CLIENT NAME reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until amendment is made,CLIENT NAME is required by law to comply with this Notice. Should our privacy practices change, we will provide all current and future patients with a copy of the revised Notice of Privacy Practices
Effective ADD DATE
III. Complaints Regarding Privacy Practices
Complaints about this Notice of Privacy Practices or how CLIENT NAME handles your health information should be directed to:
CITY, STATE ZIP CODE
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to one of the following:
Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, SW Room 509F, HHH Building
Washington, DC 20201
Department of Drug and Alcohol Programs
Bureau of Quality Assurance for Prevention and Treatment
State Health and Human Services
Oregon Department of Human Services
500 Summer St. NE E-15
Salem, OR 97301
You may also address your complaint to one of the regional U.S Department of Health and Human Services Offices for Civil Rights. A list of these offices can be found online at: https://www2.ed.gov/about/offices/list/ocr/addresses.html