Policy: It is the policy of MHA to keep all information regarding a person receiving services confidential, in compliance with all applicable state and federal laws and regulations. Confidential information includes the person’s name, social security number, address, date of birth, and any other data, which may identify them. Confidential information also pertains to Protected Health Information (PHI) as delineated in the Health Insurance Portability and Accountability Act (HIPAA) and 42CFR Part 2, “Confidentiality of Alcohol and Drug Abuse Patient Records”.
I. How We Will Use and Disclose Health Information
We will use and disclose health information as described in each category listed below. For each category, we will explain what we mean in general, but not describe all specific uses or disclosures of health information.
A. Uses and Disclosures That May Be Made For Treatment, Payment and Operations
1. For Treatment. We will use and disclosure your health information without authorization to provide health care and any related services. We will also use and disclose health information to coordinate and manage health care and related services. For example, we may need to disclose information to a case manager who is responsible for coordinating care. We may also disclose health information without authorization among our clinicians and other staff (including clinicians other than therapist or principal clinician), who work at MHA. For example, our staff may discuss care at a case conference.
In addition, we may disclose health information to another healthcare provider (e.g., your primary care physician or a laboratory) who is involved in care but is working outside of MHA.
2. For Payment. We may use or disclose health information without authorization so that the treatment and services received are billed to, and payment is collected from, a health plan or other third party payer. By way of example, we may disclose health information to permit health plan to take certain actions before health plan approves or pays for services. These actions may include:
· making a determination of eligibility for services
· reviewing services for purposes of utilization review, to ensure the appropriateness of care, or to justify the charges for care.
For example, a third party payor may ask us to share health information in order to determine if services are billable on a certain day.
3. For Health Care Operations. We may use and disclose health information without authorization for our health care operations. These uses and disclosures are necessary to run our organization and make sure that our consumers receive quality care. These activities may include, by way of example, quality assessment and improvement, reviewing the performance or qualifications of our clinicians, training students in clinical activities, licensing, accreditation, business planning and development and general administrative activities. We may combine health information of many of our consumers to decide what additional services we should offer, what services are no longer needed, and whether certain new treatments are effective. We may also combine our health information with health information from other providers to compare how we are doing and see where we can make improvements in our services. When we combine our health information with information of other providers, we will remove identifying information so others may use it to study health care or health care delivery without identifying specific clients.
We may also use and disclose health information to make contact for appointment reminders.
Finally, we may use and disclose health information to provide information about possible treatment options or alternatives that may be of interest.
4. Health-Related Benefits and Services. We may use and disclose health information about health-related benefits or services that may be of interest. If person served does not want us to provide information about health-related benefits or services, person served must notify the Division Director in writing at the address provided, clearly that they do not want to receive materials about health-related benefits or services.
B. Uses and Disclosures That May be Made Without Your Authorization, But for Which You Will Have an Opportunity to Object
Persons Involved in Your Care. We may provide health information to someone who helps pay for care. We may use or disclose health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for care of location, general condition or death. We may also use or disclose health information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures for this purpose to family or other individuals involved in health care. In limited circumstances, we may disclose health information to a friend or family member who is involved in care. If person served is physically present and have the capacity to make health care decisions, health information may only be disclosed with agreement to persons designated to be involved in care.
But, if in an emergency situation, we may disclose health information to a spouse, a family member, or a friend so that such person may assist in care. In this case we will determine whether the disclosure is in the best interest and, if so, only disclose information that is directly relevant to participation in care.
And, if not in an emergency situation but person served is unable to make health care decisions, we will disclose health information to:
> health care agent if we have received a valid health care proxy,
> guardian or medication monitor if one has been appointed by a court, or
Ø if applicable, the state agency responsible for consenting to care.
C. Uses and Disclosures That May be Made Without Authorization or Opportunity to Object
1. Emergencies. We may use and disclose health information without authorization in an emergency treatment situation. By way of example, we may provide health information to a paramedic who is transporting person served in an ambulance. If a clinician is required by law to treat and treating clinician has attempted to obtain authorization but is unable to do so, the treating clinician may nevertheless use or disclose health information to treat.
2. Research. We may disclose health information to researchers when their research has been approved by an Institutional Review Board or a similar privacy board that has reviewed the research proposal and established protocols to protect the privacy of health information.
3. As Required By Law. We will disclose health information when required to do so by federal, state or local law.
4. To Avert a Serious Threat to Health or Safety. We may use and disclose health information when necessary to prevent a serious and imminent threat to health or safety or to the health or safety of the public or another person. Under these circumstances, we will only disclose health information to someone who is able to help prevent or lessen the threat.
5. Organ and Tissue Donation. If person served is an organ donor, we may release health information to an organ procurement organization or to an entity that conducts organ, eye or tissue transplantation, or serves as an organ donation, bank, as necessary to facilitate organ, eye or tissue donation and transplantation.
6. Public Health Activities. We may disclose health information about person served as necessary for public health activities including, by way of example, disclosures to:
> report to public health authorities for the purpose of preventing or controlling disease, injury or disability;
> report vital events such as birth or death;
> conduct public health surveillance or investigations;
> report child abuse or neglect;
> report certain events to the Food and Drug Administration (FDA) by a person subject to the jurisdiction of the FDA including information about defective products or problems with medications;
< notify consumers about FDA-initiated product recalls;
> notify a person who may have been exposed to a communicable disease or who is at risk of contracting or spreading a disease or condition;
> notify the appropriate government agency if we believe an adult has been a victim of abuse, neglect or domestic violence. We will only notify an agency if we obtain your agreement or if we are required or authorized by law to report such abuse, neglect or domestic violence.
7. Health Oversight Activities. We may disclose health information about to a health oversight agency for activities authorized by law. Oversight agencies include government agencies that oversee the health care system, government benefit programs such as Medicare or Medicaid, other government programs regulating health care and civil rights laws.
8. Disclosures in Legal Proceedings. We may disclose health information to a court when a judge orders us to do so. We also may disclose health information in legal proceedings without permission or a judge’s order when:
> person served is a party to a legal proceeding and we receive a subpoena for health information. Normally, we will not provide this information in response to a subpoena without authorization if the request is for substance abuse records or for information relating to AIDS or HIV status or genetic testing;
> health information involves communications made during a court ordered psychiatric examination;
> person served introduces mental or emotional condition in evidence in support of your claim or defense in any proceeding and the judge approves our disclosure of your health information;
> person served sues any of our clinicians or staff for malpractice or initiate a complaint with a licensing board against any of our clinicians;
> the legal proceeding involves child custody, adoption or dispensing with consent to adoption and the judge approves our disclosure of your health information;
> one of our social workers brings a proceeding, or is asked to testify in a proceeding, involving foster care of a child or commitment of a child to the custody of the Massachusetts Department of Children and Families.
9. Law Enforcement Activities. We may disclose health information to a law enforcement official for law enforcement purposes when:
> person served agrees to the disclosure; or when the information is provided in response to an order of a court; or
> we determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by person served against self or another person; or
> the disclosure is otherwise required by law.
We may also disclose health information about a client who is a victim of a crime, without a court order or without being required to do so by law. However, we will do so only if the disclosure has been requested by a law enforcement official and the victim agrees to the disclosure or, in the case of the victim’s incapacity, the following occurs:
> the law enforcement official represents to us that (i) the victim is not the subject of the investigation and (ii) an immediate law enforcement activity to meet a serious danger to the victim or others depends upon the disclosure; and
> we determine that the disclosure is in the victim’s best interest.
10. Medical Examiners or Funeral Directors. We may provide health information about our consumers to a medical examiner. Medical examiners are appointed by law to assist in identifying deceased persons and to determine the cause of death in certain circumstances. We may also disclose health information about our consumers to funeral directors as necessary to carry out their duties.
11. Military and Veterans. If person served is a member of the armed forces, we may disclose your health information as required by military command authorities. We may also disclose health information for the purpose of determining your eligibility for benefits provided by the Department of Veterans Affairs. Finally, if person served is a member of a foreign military service, we may disclose your health information to that foreign military authority.
12. National Security and Protective Services for the President and Others. We may disclose medical information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We may also disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or so they may conduct special investigations.
13. Inmates. If person served is an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information to the correctional institution or law enforcement official.
14. Workers’ Compensation. We may disclose health information to comply with the Massachusetts Workers’ Compensation Law. These disclosures will usually be made only when we have received a court order or, sometimes, when we have received a subpoena for the information.
Ill. Uses and Disclosures of Health Information with Permission. Uses and disclosures not described in Section II of this Notice of Privacy Practices will generally only be made with your written permission, called an “authorization.” Person served has the right to revoke an authorization at any time. If authorization is revoked we will not make any further uses or disclosures of health information under that authorization, unless we have already taken an action relying upon the uses or disclosures previously authorized.
IV. Rights Regarding Health Information
A. Right to Inspect and Copy
Person served has the right to request an opportunity to inspect or copy health information used to make decisions about care — whether they are decisions about treatment or payment of care. Usually, this would include clinical and billing records, but not psychotherapy notes.
Person served must submit request in writing to our Division Director at the address provided. If requesting a copy of the information, we may charge a fee for the cost of copying, mailing and supplies associated with request.
We may deny request to inspect or copy health information in certain limited circumstances. In some cases, person served will have the right to have the denial reviewed by a licensed health care professional not directly involved in the original decision to deny access. We will inform in writing if the denial of request may be reviewed. Once the review is completed, we will honor the decision made by the licensed health care professional reviewer.
B. Right to Amend.
For as long as we keep records. Person served has the right to request us to amend any health information used to make decisions about care and whether they are decisions about treatment or payment of care. Usually, this would include clinical and billing records, but not psychotherapy notes.
To request an amendment, submit a written document to our Division Director at the address provided on page one of this notice and tell us why it is believed the information is incorrect or inaccurate.
We may deny request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny request if we are ask us to amend health information that:
> was not created by us, unless the person or entity that created the health information is no longer available to make the amendment;
> is not part of the health information we maintain to make decisions about care;
> is not part of the health information that you would be permitted to inspect or copy; or
> is accurate and complete.
If we deny request to amend, we will send a written notice of the denial stating the basis for the denial and offering the opportunity to provide a written statement disagreeing with the denial. If person served does not wish to prepare a written statement of disagreement, they may ask that the requested amendment and our denial will be attached to all future disclosures of the health information that is the subject of request.
If person served chooses to submit a written statement of disagreement, we have the right to prepare a written rebuttal to the statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that are the subject of request.
C. Right to an Accounting of Disclosures.
Person served has the right to request that we provide an accounting of disclosures we have made of health information. An accounting is a list of disclosures. But this list will not include certain disclosures of health information, by way of example, those we have made for purposes of treatment, payment, and health care operations.
To request an accounting of disclosures, submit request in writing to the Division Director at the address provided. For convenience, submit request on a form called a “Request for Accounting,’ which you may obtain from our Division Director. The request should state the time period for which to receive an accounting. This time period should not be longer than six years and not include dates before January 1, 2010.
The first accounting requested within a twelve month period will be free. For additional requests during the same 12 month period, we will charge for the costs of providing the accounting. We will notify of the amount we will charge and person served can choose to withdraw or notify request before we incur any costs.
D. Right to Request Restrictions.
Person served has the right to request a restriction on the health information we use or disclose for treatment, payment or health care operations. Person served may also ask that any part (or all) of health information not be disclosed to family members or friends who may be involved in care or for notification purposes.
Person served must request the restriction in writing and addressed to the Division Director at the address provided. The Division Director will request a Request for Restriction Form, which should be completed and returned to the Division Director.
We are not required to agree to a restriction that is requested. If we do agree, we will honor request unless the restricted health information is needed to provide emergency treatment.
E. Right to Request Confidential Communications.
Person served has the right to request that we communicate about health care only in a certain location or through a certain method. For example, it can be requested that we make contact only at work or by e-mail. To request such a confidential communication; make request in writing to the Division Director at the address provided. We will accommodate all reasonable requests. A reason for the request is not needed; but request must specify how and where you wish to be contacted.
F. Right to a Paper Copy of Notice of Privacy Practices.
Person served has the right to obtain a paper copy of the agency Notice of Privacy Practices at any time. If person served agreed to receive this Notice of Privacy Practices electronically, they may still obtain a paper copy. To obtain a paper copy, contact our Division Director at the address provided.
V. Confidentiality of Substance Abuse Records
For individuals who have received treatment, diagnosis or referral for treatment from our drug or alcohol abuse programs, the confidentiality of drug or alcohol abuse records is protected by federal law and regulations. As a general rule, we may not tell a person outside the programs of attendance any of these programs, or disclose any information identifying as an alcohol or drug abuser, unless:
> authorized the disclosure in writing; or
> the disclosure is permitted by a court order; or
> the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation purposes; or
> person served threatens to commit a crime either at the drug abuse or alcohol program or against any person who works for our drug abuse or alcohol programs.
A violation by us of the federal law and regulations governing drug or alcohol abuse is a crime. Suspected violations may be reported to the Unites States Attorney in the district where the violation occurs.
Federal law and regulations governing confidentiality of drug or alcohol abuse permit us to report suspected child abuse or neglect under state law to appropriate state or local authorities.
Please see 42 U.S.C. § 290dd-2 for federal law and 42 C.F.R., Part 2 for federal regulations governing confidentiality of alcohol and drug abuse patient records.
If person served believes privacy rights have been violated, they may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Complaint Officer at MHA, 995 Worthington Street, Springfield, MA 01109. All complaints must be submitted in writing.
Our Division Director, who can be contacted at the address provided, will assist you with writing your complaint, if you request such assistance.
We will not retaliate for filing a complaint.
VII. Changes to this Notice
We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at our main office and at each site where we provide care. Obtain a copy of the current Notice of Privacy Practices by requesting of our Division Director, at the address provided, that a copy be sent to in the mail or by asking for one at our offices.