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. State and federal law protects the confidentiality of this information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. The confidentiality of alcohol and drug abuse patient records is specifically protected by Federal law and regulations. Cumberland Heights Foundation is required to comply with these additional restrictions. This includes a prohibition, with very few exceptions, on informing anyone outside the program that you attend the program or disclosing any information that identifies you as an alcohol or drug abuser. The violation of Federal laws or regulations by this program is a crime. If you suspect a violation you may file a report to the appropriate authorities in accordance with Federal regulations.
How We May Use and Disclose Health Information About You
- For Treatment. We may use medical and clinical information about you to provide you with treatment or services.
- For Payment. With your authorization, we may use and disclose medical information about you so that we can receive payment for the treatment services provided to you.
- For Health Care Operations. We may use and disclose your protected health information (“PHI”) for certain purposes in connection with the operation of our program.
- Without Authorization. Applicable law also permits us to disclose information about you without your authorization in a limited number of other situations, such as with a court order. These situations are explained on the following pages.
- With Authorization. We must obtain written authorization from you for other uses and disclosure of your PHI.
Your Rights Regarding Your PHI. You have the following rights regarding PHI we maintain about you:
- Rights of Access to Inspect and Copy. You have the right, which may be restricted in certain circumstances, to inspect and copy PHI that may be used to make decisions about your care. 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 us to amend the information although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures that we make of your PHI.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use 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 locations.
- Right to a copy of this Notice. You have a right to a copy of this notice
- You have the right to file a complaint in writing to us or the Secretary of Health and Human Service if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.
Chris Berkey, Director of Quality Management
8283 River Road, Nashville, TN 37209 (615) 352-1757 firstname.lastname@example.org
This Notice of Privacy Practices describes how we may use and disclose your protected health information (“PHI”) in accordance with all applicable law. 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 Privacy Practices. We reserve the right to change the terms of our 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 make available a revised Notice of Privacy Practices by posting a copy on this website www.cumberlandheights.org, 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
Listed below are examples of the uses and disclosures that Cumberland Heights Foundation may make of your protected health information. These examples are not meant to be exhaustive. Rather, they describe types of uses and disclosures that may be made.
Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
Treatment. Your PHI may be used and disclosed by your physician, counselor, program staff and others outside of our program that are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and any related services. This includes coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care treatment. For example, your protected health information may be provided to the state agency that referred you to our program to ensure that you are participating in treatment. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of the program, becomes involved in your care.
Payment. We will not use your PHI to obtain payment for your health care services without your written authorization. Examples of payment-related activities are: making a determination of 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.
Healthcare Operations. We may use or disclose, as needed, your PHI in order to support the business activities of our program including, but not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician or counselor. We may also call you by name in the waiting room when it is time to be seen. We may share your PHI with third parties that perform various business activities (e.g. billing or typing services) for Cumberland Heights Foundation, provided we have a written contract wit the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI.
We may contact you to remind you of your appointments or to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also contact you concerning Cumberland Heights Foundation’s fundraising activities.
Other Uses and Disclosures That Do Not Require Your Authorization
Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Under the law, we must make disclosures 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.
Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.
Medical Emergencies. We may use or disclose your protected health information in a medical emergency situation to medical personnel only. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the initial mandated report.
Deceased Patients. We may disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations; and (d) the researchers agree not to redisclose your PHI except back to Cumberland Heights Foundation.
Criminal Activity on Program Premises/Against Program Personnel. We may disclose your PHI to law enforcement officials if you have committed a crime on program premises or against program personnel.
Court Order. We may disclose your PHI if the court issues an appropriate order and follows required procedures.
Uses and Disclosures of PHI with Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization at any time unless the program, or its staff, has taken action in reliance on the authorization of the use or disclosure you permitted.
Rights Regarding Your Protected Health Information
Your rights with respect to your protected health information are explained below. Any request with respect these rights must be in writing. A brief description of how you may exercise these rights is included.
You have the right to inspect and copy your Protected Health Information
You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the record. A “designated record set” contains medical and billing records and any other records that the program uses for making decisions about you. Your request must be in writing. We may charge you a reasonable cost-based fee for the copies. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right to appeal the denial of access. Please contact our Privacy Officer if you have questions about access to your medical record.
You may have the right to amend your Protected Health Information
You may request, in writing, that we amend your PHI that has been included in a designated record. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of it. Please contact Cumberland Heights Privacy Officer if you have questions about amending your medical records.
You have the right to receive an accounting of some types of Protected Health Information disclosures
You may request an accounting of disclosures for a period of up to six years, excluding disclosures made to you, made for treatment purposes or made as a result of your authorization. We may charge you a reasonable fee if you request more than one accounting in any 12 month period. Please contact our Privacy Officer if you have questions about accounting of disclosures.
You have the right to receive a paper copy of this notice
You have the right to obtain a copy of this notice from us. Any questions should be directed to our Privacy Officer.
You have the right to request added restrictions on disclosures and uses of your Protected Health Information
You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or healthcare operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions. Please contact our Privacy Officer if you would like to request restrictions on the disclosure of your PHI.
You have a right to request confidential communications
You have the right to request confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable, written request. We may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. We will not ask you why you are making the request. Please contact the Privacy Officer if you would like to make this request.
If you believe we have violated your privacy rights, you may file a complaint in writing to us by notifying our Privacy Officer, Chris Berkey at 8283 River Road Pike, Nashville, TN 37209, (615) 352-1757 or by e-mail at email@example.com. We will not retaliate against you filing a complaint. You must also file a complaint with the U.S. Secretary of Health and Human Services as follows:
Washington, D.C. 20201