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 is to explain the rules around the privacy of your own medical/health records and our legal duties on how to protect the privacy of your medical/health records that we create or receive. Generally, we are required by law to ensure that medical/health information that identifies you is kept private. We are required by law to follow the terms of the Notice that are the most current.

This Notice will explain:

• how we may use and disclose your medical/health information,
• our obligations related to the use and disclosure of your medical/health information and
• your rights related to any medical health information that we have about you.

This Notice applies to the medical/health records that are generated in or by this facility. The terms “medical” and “medical/health” in this Notice means information about your physical or mental condition which make you eligible for our services, or which arise while we are serving you. For example, this may include psychological tests, psychiatric assessments or medical or social assessments.

We may obtain, but we are not required to, your consent for the use or disclosure of your protected health information for treatment, payment or health care operations. We are required to obtain your authorization for the use or disclosure of your information for other specific purposes or reasons. We have listed some of the types of uses or disclosures below. Not every possible use or disclosure is covered, but all of the ways that we are allowed to use and disclose information will fall into one of the categories.

If you have any questions about the content of this Notice of Privacy Practices, or if you need to contact someone at the facility about any of the information contained in this Notice of Privacy Practices, the contact person is the Privacy Officer or designee: Geoffrey Cowan, 1500 N. 6th St., Ponca City, OK 74601, (580) 762-7561.

In addition to facility departments, employees, staff and other facility personnel, the following people will also follow the practices described in this Notice of Privacy Practices:

• Any health care professional who is authorized to enter information in your medical/health record;
• Any member of a volunteer group that we allow to help you while you are in the facility; and
• All providers that Edwin Fair Community Mental Health Center, Inc. contracts with to provide services to our consumers.

These other individuals or providers are considered part of Edwin Fair Community Mental Health Center, Inc. and should follow the terms of this Notice of Privacy Practices.

In addition, individuals and providers at Edwin Fair Community Mental Health Center, Inc. may share medical/health information with each other about consumers they serve in common for the purpose of treatment, payment or health care operations as those terms are described later in this Notice of Privacy Practices.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical/health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

USE AND DISCLOSURE OF MEDICAL INFORMATION

We can use or disclose medical/health information about you regarding your treatment, payment for services, or for facility operations, and we will make a good faith effort to have you acknowledge your copy of the Notice of Privacy Practices.

TREATMENT – We may use medical/health information about you to provide you with treatment or services. We may disclose medical information about you to mental health professionals or to qualified counselors, practicum students or residents, or other facility personnel, volunteers or interns who are involved in providing services for you at the facility, or interpreters needed in order to make your treatment accessible to you. For example, your treatment team members will internally discuss your medical/health information in order to develop and carry out a plan for your services.

PAYMENT – We may use and disclose medical/health information about you so that the treatment and services you receive at the facility may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to provide your insurance plan information about psychiatric treatment or habilitation services you received at the facility so your insurance plan, or any applicable Medicaid or Medicare funds, will pay us for the services. We may also tell your insurance plan or other payer about a service you are going to receive in order to obtain prior approval or to determine whether the service is covered.

HEALTH CARE OPERATIONS – Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may use and disclose medical/health information about you for facility operations. These uses and disclosures are necessary to run the facility and make sure that all of our consumers receive quality care.

USES AND DISCLOSURE OF MEDICAL/HEALTH INFORMATION THAT DO NOT REQUIRE YOUR CONSENT OR AUTHORIZATION

We can use or disclose health information about you without your consent or authorization when:

ª there is an emergency or when we are required by law to treat you,
• when we are required by law to use or disclose certain information, or
• when there are substantial communication barriers to obtaining consent from you.

We can also use or disclose health information about you without your consent or authorization for:

APPOINTMENT REMINDERS – We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or services at the facility.

TREATMENT ALTERNATIVES AND HEALTH-RELATED BENEFITS AND SERVICES – We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services that may be of interest to you.

INDIVIDUALS INVOLVED IN DISASTER RELIEF – Should a disaster occur, we may disclose medical information about you to any agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

RESEARCH – Under certain circumstances, we may use and disclose medical/health information about you for research purposes when a waiver of authorization has been approved. For example, a research project may involve comparing the health and recovery of all consumers who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process under Oklahoma law. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with consumers’ need for privacy of their medical/health information. Before we use or disclose medical/health information for research, the project will have been approved through this research approval process. We may, however, disclose medical/health information about you to people preparing to conduct a research project, for example, to help them look for consumers with specific medical needs, so long as the medical information they review does not leave the facility. We may also use or disclose your health information without your consent when disclosing information related to a research project when a waiver of authorization has been approved.

AS REQUIRED BY LAW – We will disclose medical/health information about you when required to do so by federal, state or local law.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY – We may use and disclose medical/health information about you when necessary to prevent a serious threat to the health and safety of you, the public, or any other person. However, any such disclosure would only be to someone about to help prevent the threat.

SPECIAL SITUATIONS

MILITARY AND VETERANS – If you are a member of the armed forces, we may release medical/health information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

WORKERS’ COMPENSATION – When disclosure is necessary to comply with Workers’ Compensation laws or purposes, we may release medical/health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

PUBLIC HEALTH RISKS – We may disclose medical/health information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a consumer has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

HEALTH OVERSIGHT ACTIVITIES – We may disclose medical/health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

LAWSUITS AND DISPUTES – If you are involved in a lawsuit or a dispute, we may disclose medical/health information about you in response to a court or administrative order.

LAW ENFORCEMENT – We may release medical/health information if asked to do so by a law enforcement official; however, if the material is protected by 42 CFR Part 2 (a federal law protecting the confidentiality of drug and alcohol abuse treatment records), a court order is required. We may also release limited medical/health information to law enforcement in the following situations: (1) about a consumer who may be a victim of a crime, if, under certain limited circumstances, we are unable to obtain the consumer’s agreement; (2) about a death we believe may be the result of criminal conduct; (3) about criminal conduct at the facility; (4) about a consumer where a consumer commits or threatens to commit a crime on the premises or against program staff (in which case we may release the consumer’s name, address, and last known whereabouts); (5) in emergency circumstances, to report a crime, the location of the crime or victims, and the identity, description and/or location of the person who committed the crime; and (6) when the consumer is a forensic client and we are required to share with the law enforcement by Oklahoma statute.

CORONERS OR MEDICAL EXAMINERS – We may release medical/health information to a coroner or medical examiners. This may be necessary, for example, to identify a deceased person or determine the cause of death.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES – We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS – We may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President and other authorized persons or foreign heads of state.

INMATES – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical/health information about you to the correctional institution or law enforcement official if the release is 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.

YOUR RIGHTS REGARDING MEDICAL/HEALTH INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

RIGHT TO INSPECT AND COPY – You have the right to inspect and copy your medical/health information with the exception of therapy notes and information compiled in anticipation of litigation. To inspect and copy your medical/health information, you must submit your request in writing to this facility’s Privacy Officer or designee. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical/health information because of a threat or harm issue, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

RIGHT TO REQUEST AN AMENDMENT – If you feel that medical/health information we have about you is incorrect or incomplete; you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the facility. Requests for an amendment must be made in writing and submitted to the Privacy Officer or designee. You must provide a reason to support your request for an amendment. We may deny your request if it is not in writing or if it does not include a reason supporting the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the facility;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

RIGHT TO AN ACCOUNTING OF DISCLOSURES – You have the right to request an “accounting of disclosures: a list of the disclosures made by the facility of your medical/health information. To request an accounting of disclosure, you must submit your request in writing to this facility’s Privacy Officer or designee. Your request must state a time period which may not go back more than six years and cannot include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists in a twelve-month period, we may charge you for the cost of providing the list. We will notify you what that cost will be and give you an opportunity to withdraw or modify your request before you are charged. There are some disclosures that we do not have to track. For example, when you give us an authorization to disclose information, we do not have to track that disclosure.

RIGHT TO REQUEST RESTRICTIONS – You have the right to request a restriction or limitation on the medical/health information we use or disclose about you for treatment, payment or health care operations. For example, you could ask that we not use or disclose information about your family history to a particular community provider. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction on the use or disclosure of your medical/health information for treatment, payment or health care operations, you must make your request in writing to the facility’s Privacy Officer or designee. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS – You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the facility’s Privacy Officer or designee. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request and will accommodate all reasonable requests.

RIGHT TO A PAPER COPY OF THIS NOTICE – You have the right to a paper copy of this Notice even if you have agreed to receive the Notice electronically. You may ask us to give you a copy of this Notice at any time by contacting the facility’s Privacy Officer or designee.


CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We may make the revised Notice effective for medical/health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the facility. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted or apply for services to the facility for treatment or services, we will offer you a copy of the current Notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated,

• You may file a complaint with the facility or with the Secretary of the Department of Health and Human Services.
• You may call them at 877-696-6775 or write to them at 2000 Independence Ave. S.W., Washington, D.C. 20201
• You may file a grievance with the Office of Civil Rights by calling 866-OCR-PRIV (866-627-7748), or 886-788-4989 TTY.

To file a complaint with the facility, contact the Privacy Officer or Designee, at the following address and telephone number: Geoffrey Cowan, 1500 N. 6th St., Ponca City, OK 74601, (580) 762-7561

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OR DISCLOSURES OR MEDICAL/HEALTH INFORMATION

Uses or disclosures not covered in this Notice of Privacy Practices will not be made without your written authorization. If you provide us written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as it is in writing. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization.