CATHOLIC HUMAN SERVICES, INC.
NOTICE OF PRIVACY PRACTICES
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.
Your records and personal information are protected under federal regulations governing the privacy, confidentiality and security of personal health information (42 CFR, Part 2, and 45 CFR Parts 160 and 164). This means that Catholic Human Services may not say to a person outside of the program that you attend the program or receive services, or release confidential information without authorization. When you sign the "Fee Agreement" form, you are asked to consent, or give us permission to provide information for the purposes of billing, utilization review and payment. Examples of these activities are: providing the date and type of service to your insurance or to Medicaid so we can be paid for the service, or providing other treatment information so that your insurance company or managed care company can evaluate your claim for insurance coverage. You must give us permission (or "authorization") to disclose your information, and that permission must be given in writing. We use special forms for that purpose. You have the right to revoke the authorization at any time in writing, unless we have already taken action on it. We are authorized to release information without your authorization when:
- The disclosure (giving the information) is allowed by a court order
- The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation
- The disclosure is made about a crime committed at the program or against any person who works for the program or about any threat to commit such a crime
- The disclosure is about suspected abuse or neglect, as required by state law
- The disclosure is made to individuals outside our agency who have authority to conduct reviews or audits regarding funding, licensing or accreditation requirements
You have the following rights to:
- Request a restriction on certain uses or disclosures of your personal information. We may not agree to your requested restrictions under certain circumstances
- Request how and where we contact you about personal health information
- See and copy your client record unless a clinical supervisor recommends otherwise. If the request is denied you have the right to another independent review of your request
- Request an amendment (to correct information in your records)
- Request a list (or "accounting") of disclosures we have made. (Exceptions include disclosures prior to April 14, 2003, disclosures for your treatment, billing, and those that you authorize.)
- Receive a paper copy of this Notice upon request
- Make complaints about our privacy practices
Complaints of questions about this notice can be expressed to one of the agencyâs Recipient Rights Advisors as follows: Alpena 989-356-6385; Gaylord 989-732-6761; Traverse City 231-947-8110; Cadillac 231-775-6581. You may also speak to the clinical supervisor of the office where you receive services, State rights advisors, or the federal Office for Civil Rights. See the client Orientation booklet for detailed instructions on making complaints to Catholic Human Services or other agencies, along with addresses and phone numbers to contact. There will be no retaliation against you for filing a complaint.
Catholic Human Services may contact you by phone or regular mail to provide appointment reminders or to change appointments, to give you information about treatment recommendations or treatment alternatives, or to provide information about health related services or benefits that may be of interest to you. Any requests you wish to make about these rights, or if you want more information on how to exercise these rights, please ask to speak to the Rights Advisor or clinical supervisor for this office.
Catholic Human Services is required by federal and state laws to protect the privacy, security and confidentiality of your personal information. We are also required to provide you with this notice of our legal duties and privacy policies. We are required to follow the laws and duties outlined in this notice. We may revise our privacy practices, change the terms of this notice, and to make new notice provisions for all personal information we maintain. We will provide you with updated information verbally or in writing about any changes to this Notice.
Effective May 15, 2012