Revised: July 19, 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 THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use or disclose your PHI in accordance with applicable law and the NASW (National Association of Social Workers) Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or peer-led consultations.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. Information provided to health plans may include your diagnoses, procedures performed, or recommended care. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. We may use your PHI to remind you of an appointment, or offer you opportunities for education or additional health care options.
Under the Law. We must make disclosure of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Oregon Law. Oregon law provides additional confidentiality protections in certain circumstances. For example, in Oregon a health care provider generally may not release the identity of a person tested for HIV or the results of an HIV-related test without your consent, and you must be notified of this confidentiality right. Drug and alcohol records are specifically protected and typically require your specific consent for release under both federal and state law. Mental health records are specially protected in some circumstances, as is genetic information.
For more information on Oregon law related to these and other specially protected records, contact Inner Courage LLC, Contract Manager, at 1500 NE 15th Avenue, Suite #328, Portland, OR, 97232-4417, 503-341-4325, FAX, 503-460-1860, firstname.lastname@example.org or refer to the Oregon Revised Statutes, or to the Oregon Administrative Rules. These documents are available online at www.oregon.gov.
Without Your Authorization. In addition to the uses and disclosures listed above, applicable law and ethical standards permit me to disclose information about you without your written authorization only in a limited number of other situations. The types of uses and disclosure that may be made without your written authorization are those that are:
- Required by Law, such as the mandatory reporting of child abuse or neglect, elder abuse or neglect; or mandatory government agency audits or investigations (such as the social work licensing board or the health department);
- Incidental to certain Public Health Activities, such as when a public health authority is authorized by law to collect or receive such information for health related purposes;
- Made if we reasonably believe that you have been the subject of abuse, neglect or domestic violence, and if such disclosure is authorized by law;
- Pursuant to judicial or administrative proceedings, such as a court order, subpoena or discovery request;
- For law enforcement purposes;
- To a coroner, medical examiner, or funeral director for the purpose of identifying a deceased person, determine a cause of death, or as necessary for such persons to carry out their duties and as authorized by law;
- To organ procurement organizations as necessary to carry out their duties and as authorized by law;
- For research purposes, as long as we have obtained appropriate board approval for an alternative to or waiver of authorization;
- Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person (including yourself such as the threat of suicide or homicide) or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including informing the target of the threat.
- To comply with workers’ compensation or similar programs established by law;
- Required by law
With Your Verbal Permission. We may use or disclose your PHI to family members that are directly involved in your treatment with your verbal permission. We may also, with your verbal permission, use your name and contact information for the purpose of maintaining a directory of individuals in my facility. This information may be disclosed with your verbal permission to members of the clergy and to individuals who ask for you by name. In an emergency situation, we may disclose this information if it would be consistent with your expressed preference and if we determine that such disclosure would be in your own best interest.
With Your Authorization. Uses and disclosure not specifically permitted by applicable law will be made only with your written authorization, which may be revoked, in writing, at any time. The revocation of your authorization will not impact information released prior to the date of the written revocation.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to Inner Courage LLC, Contract Manager, at 1500 NE 15th Avenue, Suite #328, Portland, OR, 97232-4417, 503-341-4325, FAX, 503-460-1860, email@example.com m.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask me to amend the information. Although we are not required to agree to the amendment, we will attempt to accommodate any reasonable request. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included in any release of your records.
- Right to an Accounting of Disclosures. You may have the right to request an accounting of certain of the disclosure that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use of disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request
- Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with Inner Courage LLC, Contract Manager, at 1500 NE 15th Avenue, Suite #328, Portland, OR, 97232-4417, 503-341-4325, FAX, 503-460-1860, firstname.lastname@example.org; or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.
The effective date of this Notice is August 6, 2006
NOTICE OF PRIVACY PRACTICES
RECEIPT AND ACKNOWLEDGMENT OF NOTICE
I hereby acknowledge that I have received and have been given an opportunity to read a copy of the Inner Courage LLC Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Inner Courage LLC, Contract Manager, 1500 NE 15th Avenue, Suite #328, Portland, OR, 97232-4417, 503-341-4325, FAX: 503-460-1860, email@example.com
Signature of Patient/Client Date
Signature or Parent, Guardian or Personal Representative * Date
* If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
- Patient/Client Refuses to Acknowledge Receipt:
Signature of Staff Member Date
Inner Courage LLC
Notice of Privacy Practices