ARBOR COUNSELING CENTER, LTD
NOTICE OF PRIVACY PRACTICES
This Notice of Privacy practices describes how Arbor Counseling Center will keep your medical information confidential, how you can get access to your medical information, and situations in which Arbor Counseling Center may use or disclose your medical information. Please review it carefully. The privacy of your medical information is important to us. This Notice takes effect April 14, 2003 , and will remain in effect until we replace it.
Uses and Disclosures of Your Medical Information
Arbor Counseling Center will keep your medical information confidential unless we need to use or disclose it for purposes of your treatment and payment or as part of our health care operations. For example:
Treatment: We may use or disclose your medical information to a physician or other health care provider in order to provide treatment to you.
Payment: We may use and disclose your medical information to obtain payment for services we provide to you. We may disclose your medical information to another health care provider or entity subject to the federal Privacy Rules so they can obtain payment for services provided to you.
Health Care Operations: We may use and disclose your medical information in connection with our health care operations. Health care operations include:
- quality assessment and improvement activities;
- reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities;
- medical review legal services, and auditing, including fraud and abuse detection and compliance;
- business planning and development; and
- business management and general administrative activities, including management activities relating to privacy customer service, resolution of internal grievances, and compiling medical data in ways that do not identify individual patients by name. We may also disclose your medical information to another entity that has a relationship with you and is subject to the federal Privacy Rules for purposes of their health care operations.
To Your Family and Friends: We may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. We may use or disclose your name, location, and general condition or death to notify, or assist in the notification of (including identifying or locating), a person involved in your care.
Before we disclose your medical information to a person involved in your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.
We will also use our professional judgment and our experience with common practice to allow a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of medical information, prohibit some or all disclosures for patient directories unless emergency circumstances prevent your opportunity to object.
Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:
- as required by law;
- to report adult abuse, neglect, or domestic violence;
- to health oversight agencies;
- in response to court and administrative orders and other lawful processes;
- to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies and for purposes of identifying or locating a suspect or other person;
- to avert a serious threat to health or safety;
- in connection with certain research activities;
- to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
- to correctional institutions regarding inmates; and
- as authorized by state worker's compensation laws.
Disaster Relief: We may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
Health Related Services: We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. We may disclose your medical information to a business associate to assist us in these activities.
On Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those previously described in this notice.
Access: You have the right to look at or get copies of your medical information, with limited exceptions. You must make a request in writing to obtain access to your medical information, using our form. You may request that we provide the information in a format other than photocopies. We will use the format you request unless it is not practical to do so. If you request copies, we will charge you a fee, and if you request an alternative format, we will charge a cost-based fee for providing your medical information in that format. If you prefer, we will prepare a summary or an explanation of your medical information for a fee. Contact us using the information listed at the end of this notice for an Access Request form for your medical information and a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations, and for certain other activities, since April 14, 2003 . We are not required to account for disclosures authorized by you. Included in the Disclosure Accounting will be the date on which we made the disclosure, the name of the person or entity to which we disclosed your medical information, a description of the medical information disclosed, the reason for the disclosure, and certain other information. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice to obtain a Disclosure Accounting form and a full explanation of our fee structure.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in writing, signed by a person authorized to make such an agreement on our behalf.
Contact us using the information listed at the end of this notice to obtain a medical information Restriction Request form.
Confidential Communication: You have the right to request that we communicate with you about your medical information by alternative means or to alternate locations. You must make your request in writing. You must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request. Contact us using the information listed at the end of this notice to obtain a Confidential Communication Request form.
Amendment: You have the right to request that we amend your medical information. Your request must be in writing on our form, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. Contact us using the information listed at the end of this notice to obtain an Amendment Request form.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, you may complain to us using the contact information listed at the end of this notice.
You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your medical information. We are required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information under the federal HIPAA Privacy Rules. This notice takes effect April 14, 2003 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided applicable law permits such changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
Contact Office: Privacy Manager for Arbor Counseling Center
Hours: Monday – Friday, 8:00 a.m. to 4:00 p.m.