F r e m o n t C o u n s e l i n g S e r v i c e
Providing Mental Health and Substance Abuse Services to
An Equal Opportunity Provider
TTY Hearing Impaired -
1-800-877-9975
To Our Clients;
This notice describes how
information about you may be used and disclosed and how you can get access to
this information. Please review it
carefully.
Privacy regulations
in the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
require Fremont Counseling Service (FCS) to share this information with
you. Federal and state laws related to
health care and privacy are long and complicated. The information provided herein has been
shortened and simplified. If you have
any questions or want to know more information about this Notice, please ask
your clinician for more details.
Understanding what is
in your clinical record and how your clinical information is used will allow you
to make better decisions about your health.
Each time you visit
FCS, information is collected about you and your mental and physical
health. It may be information about your
past, present, or future health or medical conditions, the treatment and
services received at FCS or by other providers, or about payment for health
care.
The information we
collect from you is called Protected
Health Information (PHI). This information
is kept in your clinical record.
The PHI in your clinical record will likely include:
a) your history (as a
child, in school, at work, personal, and marital),
b) reasons for coming
to treatment (problems, complaints, symptoms, needs, and goals),
c) your diagnosis,
d) treatment plan,
e) progress notes
detailing each session or meeting,
f) records from other
providers who treat or have treated you,
g) evaluations from
other providers,
h) psychological test
scores and reports,
I) information about
medication you have taken or are taking,
j) legal history and
obligations, and
k) billing and
insurance information.
The information gathered and filed in your clinical record
is used for many reasons including, but not limited to:
a) to plan your care
and treatment,
b) to decide how well
treatment works for you,
c) to coordinate
services with other professionals who are treating you, and
d) to show you
received services for which you are another payment source were billed.
Although your health
record is the physical property of FCS, the information inside of it belongs to
you. You may inspect, read, or review it.
You may even request a copy of it, but you may be charged copying and
mailing fees. In some unusual
situations you may not be able to see the entire clinical record. If you find anything in your records that you
think is incorrect or if something important is missing you can ask us to
correct or add to your record. In rare
situations, FCS does not have to agree to correct or add to the record. Your clinician can explain more about this if
you have questions.
Privacy and the Laws
HIPAA law requires us
to keep your PHI private and to give you notice of FCS legal duties and privacy
practices called the Notice of Privacy
Practices (NPP). FCS staff will obey
the rules of this notice as long as it is in effect. If the notice changes, it will apply to all PHI
kept at FCS. The Notice of Privacy
Practices and any future changes will be posted in each office where everyone
can see them. You or anyone else can
request a copy of the NPP from the clerical staff or your clinician at any
time.
How Your PHI can be Used and Shared
HIPAA law refers to “use” of your information when any FCS
staff reads it. The information is
considered “disclosed” if the
information is shared with or sent to others not employed by FCS. Except in special circumstances, when we use
your PHI at FCS or disclose it to others, only
the minimum necessary information is used.
You have the right to know about your PHI, how it is used, and you have
a say in how it is disclosed.
FCS uses and discloses your PHI for several reasons. The law allows FCS to use or disclose some
information without your consent or authorization. For most disclosures FCS will first obtain
written Release Authorization(s) signed by you and you will be informed about
disclosures before they occur.
Use and Disclosure of PHI with your Consent
After reading this
Notice you will be asked to sign a consent form that allows FCS to share your PHI. In almost all cases FCS intends to use your
information here or share it with others to provide treatment to you, arrange
for payment of services provided by FCS, or some other business functions
called health care operations. The
consent form allows FCS to release PHI for treatment, payment, and operations.
Treatment, Payment, and Health Care Operations
It is necessary to
collect information about you and your condition to provide care to you. By signing the consent form you agree to let
FCS collect the information, use it, and when necessary share it to provide
proper care for you. If you do not agree with the consent to
treat and do not sign it, we cannot treat you.
FCS staff collect
information about you and it may all be kept in your clinical record. These are some examples of how FCS uses and
discloses your PHI. Information is
collected to provide treatment or other
services, such as individual therapy, group therapy, case management, or
job coaching. FCS may share or disclose your PHI to those who
provide treatment to you, within the
agency. Referrals for treatment outside the agency will require a
written authorization signed by you.
In the future if you receive treatment from another professional outside the agency, your PHI will only
be released with authorization signed by you.
To collect payment for services, FCS staff gathers information about you to bill
you, your insurance company, or other payees. Your insurance company may be contacted by
FCS to determine what services are covered by your policy. FCS staff may have to tell them about your
diagnosis, treatment received, and outcome expectations. FCS will need to tell them about times you
met with your clinician or other staff, your progress, and other related
information.
FCS may use or
disclose your PHI to evaluate and
improve health care operations. For
example, your information may be used to evaluate the impact of a particular
group therapy or adjust the schedule of an intensive treatment program. FCS staff may also be required to provide
some information to governmental health agencies for research and tracking
purposes. If so, your name and other identifying characteristics are removed first. If identifying information is shared, you
will be notified first and asked to sign an authorization.
Other Uses in Healthcare
Your PHI may be used to improve the quality of
services provided to you by FCS.
Your information may be used to remind you of appointments, notify you
of cancellations, or rescheduled appointments.
It may also be used to notify you of, or refer you to, other services
that may be of interest to you. It may
be used to research treatment options for you.
If you prefer a specific method to
contact you, just tell your clinician or the clerical staff. We will, to the best of our ability,
accommodate your needs and wants.
There are some
services FCS hires out to contract agencies, such as psychiatric services and
computer technicians. These contractors
are called Business Associates. These business
associates will have access to at least some of your PHI to perform their
duties. They have agreed to protect your information and privacy as it relates to their
service as FCS.
Authorization
If FCS staff want to use your PHI for any reason other than
treatment, payment, and health care operations as described above, a signed
Authorization (Release/Request) is required. Your clinician or other service provider will
ask you to complete and sign an authorization and will explain its use.
Authorizations may be revoked at any time, in writing. After receiving the written request to revoke
an authorization, no further information will be released. However, some information may have been
released while the authorization was still in effect. We cannot take back any information that was
released before the authorization was revoked.
Use and Disclosure of PHI NOT requiring Authorization
Federal and state laws allow or require FCS to use or
disclose some PHI without Authorization. Information is used or disclosed when there
is suspected neglect and/or abuse that involves children, the elderly,
disabled, and/or incompetent persons; in medical emergencies; or in cases of
life-threatening harm to self or others.
FCS may release information to law enforcement officials to investigate
a crime, if required to do so by law. FCS
may disclose PHI of military personnel and veterans to government benefit
programs related to eligibility and enrollment and to Worker’s Compensation.
Uses and Disclosures to which you may Object
FCS can share some
information about you and your family members.
FCS will only share information
with those involved in your care and anyone else you choose such as a close
friend or clergy. FCS will ask you about
who you want us to tell what information.
You can tell us what you want and we will honor your wishes as long as
it is not against the law.
If there is an
emergency, we can share information if we believe it is what you would have
wanted and if we believe it will help you if we do share it. If we do share information in an emergency,
we will tell you as soon as possible. If
you do not wish to have the information shared, we will stop, as long as it is
not against the law.
Disclosure Account
When FCS discloses
your PHI a record of whom we sent it to,
when it was sent, and what was sent is kept in your clinical record. You
can request a list of the disclosures from your clinician.
Questions or Problems
If you need more
information of have questions about the FCS privacy practices described please ask
to speak with any member of FCS staff.
If you have a problem
with how your PHI has been handled or if you believe your privacy rights have
been violated, please contact the Executive Director.
You have the right to file a complaint with FCS and the
Secretary of the U.S. Department of Health and Human Services. The U.S. Department of Health and Human
Services may be contacted at:
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
Office
for Civil Rights
Room 509F,
Velveta Howell, Regional VIII Manager (CO, MT, ND, SD, WY)
Office for Civil Rights
U.S. Department of Health and Human Services
1961 Stout Street -- Room 1426 FOB
Denver, CO 80294-3538
Voice Phone (303)844-2024
FAX (303)844-2025
TDD (303)844-3439
Your care will not be limited in any way and no actions will
be taken against you for any complaints you may file.
If you have any
questions regarding this notice or FCS health information privacy policies please
contact the Executive Director:
Executive Director
(307) 332-2231 ext. 113
This notice is
effective April 14, 2003.
Reviewed/Revised: March 2004, February 2005, September 2010