HIPPA Privacy Policy Notice and Patient Rights

HIPPA Privacy Policy Notice and Patient Rights

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print the following forms out and complete them before your next appointment. Please bring the completed forms to your initial appointment.

New Client Intake Forms

HIPPA Privacy Policy Notice and Patient Rights

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

About this Notice

This notice will tell you about the ways we may use and disclose health information that identifies you (“Health Information”). We also describe your rights and certain obligations we have regarding the use and disclosure of Health Information. We are required by law to maintain the privacy of Health Information that identifies you; give you this Notice of our legal duties and privacy practices with respect to your Health Information; and follow the terms of our Notice that are currently in effect. This notice covers the faculty of Sandia Crest Mental Health LLC.

We may disclose your information for the following Purposes:

For Treatment: We may use Health Information about you to provide you with medical treatment services. We may disclose Health Information to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example a physician taking care of you for a possible drug interaction may need to know what medications where prescribed for you.

For Payment: We may use and disclose Health Information so that we may bill for treatment and services you receive at Sandia Crest Mental Health LLC and can collect payment from you, an insurance company or another third party. The information often needed includes diagnosis codes, dates of services, your name, your address, your family members name that is insured, birth dates and your insurance identification numbers.

Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services:

We may use and disclose Health Information to contact you to remind you that you have an appointment for treatment, or to contact you to tell you about possible treatment options or health benefits and services that may be of interest to you.

Individual Involved in Your Care or Payment for Your Care:

We may release Health Information to person who is involved in your medical care or helps pay for your care, such as a family member or friend.

As Required by Law:

We will disclose Health Information about you when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety:

We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will be to someone who may be able to help prevent the threat.

Business Associates

We may disclose Health Information to our business associatiates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example we may use another company to audit our records to ensure HIPPA compliance. We may also use another company for medical billing.

Military or Veterans:

If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Law Enforcement:

We may release Health Information if asked by a law enforcement official for the following reasons: in response to a court order, subpoena, warrant, summons or similar process, limited information to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises, and in emergence circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities and Protective Services

We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We also may disclose Health Information to authorized federal officials so they may conduct special investigations and provide protection to the President, other authorized persons and foreign heads of state.

Public Health Risks:

We may disclose Health Information for public health activities. These activities generally include disclosures to: a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of and FDA-regulated product or activity; prevent or control disease, injury or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and the patient agrees or we are required or authorized by law to make such disclosure.

Health Oversight Activities:

We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, 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 Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Other Uses of Health Information:

Other uses and disclosures of Health Information not covered by this Notice or the laws that apply to us will be made only with your written permission. You may revoke your permission at any time by submitting a written request to our Privacy Officer, except to the extent that we acted in reliance on your permission.

Your Rights Regarding Health Information about you

You have the following rights, subject to certain limitations, regarding Health Information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request.

Right to Request Amendments

If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information and you must tell us the reason for your request. You have the right to request an mendment for as long as the information is kept by or for Sandia Crest Mental Health LLC. A request for amendments must be submitted, in writing, to the Privacy Officer at the address at the top of this notice.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures” of Health Information. This is a list of certain disclosures we made of Health Information. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the lists.

Right to Request Restrictions

You have the right to request restrictions or limitations on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose about you to someon who is involved in your care or the payment or your care, likely a family member or friend. We are not required to agree to your request. If we agree, we will comply with your request unless we terminate our agreement or the information is needed to provide you with emergency treatment.

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 may request that we contact you only by mail.

Right to a Paper copy of this Notice

You have the right a paper copy of this Notice, even if you have agreed to receive this notice electronically. You may request a copy of this Notice at any time.

How to Exercise Your Rights

To exercise your rights described in this notice, send your request, in writing, to our Privacy Office at the address listed above. Alternatively, to exercise your right to inspect and copy Health Information, you may contact your clinician office directly.

Your responsibilities

As a client, you also have some responsibilities to yourself, to other clients and to the center/clinic. Read about them carefully and be sure to ask your provider if you have any questions about them.

Client has the responsibility:

• To participate in the development of your treatment plan

• To provide the best of his/her knowledge, accurate and complete information about: present complaints, past illnesses, hospitalizations, medications, advanced directives and other matters relevant to care.

• To adhere to TCC/SCMH LLC policies and procedures including those regarding weapons and safety

• To attend sessions sober

• To notify TCC/SCMH LLC providers of change of condition

• To follow his/her individual treatment/care plan

• To notify TCC/SCMH LLC providers if treatment/care plan or schedule needs to be changed

• To inform TCC/SCMH LLC providers of any problems or dissatisfactions with the services provided.

• To carry out mutually agreed upon responsibilities

• To meet financial obligation and commitment

• To treat provides with dignity and respect

• To provide a safe environment for cae to be provided when such care is being provided in his/her private home

• To notify TCC/SCMH LLC provider if another provider has changed medications or is involved in your mental health care.

• To notify clinician at least 24-48 hours prior to your appointment if you cannot make your scheduled appointment.

Consent for Treatment:

I understand that the primary staff person(s) assigned to me will explain the nature of treatment to be provided, the expected benefits and risks, and alternatives available. I also understand that although a reasonable standard of care will be provided, improvement, though expected is not guaranteed. If I wish to withdraw from treatment at any time a staff person will help me with an appointment referral. If I refuse care or treatment, a staff person will inform me of the foreseeable risks associated with such refusal of care or treatment.

Confidentiality and Release of Information:

I understand that the information concerning my contacts with the program will be held confidential to protect my right to privacy. I further understand that such information will not be disclosed without my written consent or that of my legal guardian, except under special circumstances such as:

• If I threaten to injure my self or someone else, or,

• When such information is required by law to be reported, such as information regarding abuse, neglect, molestation, or exploitation of a minor, incapacitated adult, elder person 65 or older, or incase of a court order, or,

• Pertinent parts of my medical record and/or financial records pertaining to my treatment for the purpose of quality improvement activities.