PRIVACY NOTICE

This Notice Describes How Medical Information About You May Be Used And Disclosed And Your Rights To Access Your Health Information. Please Review It Carefully !

The Institute is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, state laws and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, diagnosing your problem, treating the issues in a therapeutic milieu and applying for future care or treatment. It also includes billing documents for those services

Understanding Your Mental Health Record Information

Each time you visit a healthcare provider, the provider makes a record of your visit. Typically, this record may contain your health history, current symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your medical record, serves as a:

Basis for planning your care and treatment.
Means of communication among the many health professionals who contribute to your care.
Legal document describing the care you received.
Means by which you or a third-party payer can verify that you actually received the services billed for.
A tool in medical education.
A source of information for public health officials charged with improving the health of the regions they serve.
A tool to assess the appropriateness and quality of care you received.
A tool to improve the quality of healthcare and achieve better patient outcomes.

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Understanding what is in your health records and how your health information is used helps you to:

Ensure its accuracy and completeness.
Understand who, what, where, why, and how others may access your health information.
Make informed decision about authorizing disclosure to others.
Better understand the health information rights detailed below.

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Your record is a clinical evaluation based on information from many sources. It contains highly personal material and will not be released to you or your family, without a qualified mental health professional to review and interpret it for you. State and Federal laws require that this record be used only by appropriate people, and only the minimal necessary information will be released.

Your Rights Under the Federal Privacy Standard

Although your health records are the physical property of the healthcare provider who completed it, you have certain rights with regard to the information contained therein. You have the right to:

Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. “Health care operations” consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under §§ 164.502 (A)(2)(i) (disclosures to you), 164.510(a) (for facility directories, but note that you have the right to object to such uses), or 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as but not limited to: 1) in the case of communicable disease mandatory reporting, 2) in the course of any judicial or administrative proceeding as allowed or required by law with your authorization or as directed by a proper court order 3) to avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lesson a serious, imminent threat to the health or safety of a person or the public.In those cases, you do not have a right to request restriction.
The Consent to use and disclose your individually identifiable health information provides the ability to request restriction. We do not, however, have to agree to the restriction. If we do, however, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means and, if the method of communication is reasonable, we must grant the alternate communication request. Again see the consent form.
Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.
Inspect your health information upon request with a qualified mental health professional. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
- Psychotherapy notes. Such notes comprise those that are recorded in any medium by a healthcare provider who is a mental health professional documenting or analyzing a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record.
- Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
- PH1 that is subject to the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”), 42 U.S.C. § 263a, to the extent that the provision of access to the individual would be prohibited by law.
- Information was obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

In other situations, the provider may deny you access but, if it does, the provider must provide you with a review of the decision denying access. These “reviewable” grounds for denial include:

Licensed healthcare professional has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of the individual or another person.
PH1 makes reference to another person (other than a healthcare provider) and a licensed healthcare provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
The request is made by the individual’s personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that the provider of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review.

If we grant access, we will tell you what, if anything, you have to do to get access.

We reserve the right to charge a reasonable, cost-based fee for making copies.

Request amendment/correction of your health information. We do not have to grant the request if:
- We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If they amend or correct the record, we will put the corrected record in our records.
- The records are not available to you as discussed immediately above.
- The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those you identify to us that you want to receive the corrected information.

Obtain an accounting of “non-routine” uses and disclosures-those other than for treatment, payment, and health care operations. To individuals of protected health information about them. We do not need to provide an accounting for:
- For the facility directory or to persons involved in the individual’s care or other notification purposes as provided in §164.510 (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for the care of the individual, of the individual’s location, general condition, or death).
- For national security or intelligence purposes under § 164.512 (k)(2) (disclosures not requiring consent, authorization, or an opportunity to abject, see chapter 16).
- To correctional institutions or law enforcement officials under § 164.512(k)(5) (disclosures not requiring consent, authorization, or an opportunity to object).
- That occurred before April 14, 2003.
- We must provide the accounting within 60 days. The accounting must include:
  1. Date of each disclosure.
  2. Name and address of the organization or person who received the protected health information.
  3. Brief description of the information disclosed.
  4. Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of the written request for disclosure.
- The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.
Revoke your consent or authorization to use or disclose health information except to the extent that we have already taken action in reliance on the consent or authorization.

Our Responsibilities Under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to:

Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
Provide you with this notice as to our legal duties and privacy practices with respect to individually identifiable health information we collect and maintain about you.
Abide by the terms of this notice.
Train our personnel concerning privacy and confidentiality.
Implement a sanction policy to discipline those who breach privacy or confidentiality.
Mitigate (lessen the harm of) any breach of privacy/confidentiality.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION WE MAINTAIN. SHOULD WE CHANGE OUR INFORMATION PROCTICES, WE WILL MAIL A REVISED NOTICE TO THE ADDRESS YOU HAVE SUPPLIED US.

We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

How to Get More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact the [Privacy Officer] at 303-238-1231. You may complain to us if you believe that we have violated your privacy rights. You may also file a complaint with the Secretary of the United States Department of Health and Human Services.

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use your health information for treatment:
Example: A physician, nurse, and/or other clinical member of our healthcare team will record information in your record to diagnose your condition and determine the best course of treatment for you. The Clinical Team will give treatment orders and document what they expect other members of the healthcare team to do to treat you. Those members will then document the actions they took and their observation. In that way, the Clinical Team will know how you are responding to treatment.

We will also provide your physician, other healthcare professionals, or a subsequent healthcare provider with copies of your records to assist them in treating you once we are no longer treating you.

We will use your health information for payment:
Example: We may send a bill to you or to a third-party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received, and supplies used.

We will use your health information for health operations:
Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality assurance team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.

Business associates: We provide some services through contracts with business associates. Examples include certain diagnostic tests, a copy service to make copies of medical records, and the like. When we use these services, we may disclose your health information to the business associate so that they can perform the function(s) we have contracted with them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use your name and general condition. This information may be provided to people who ask for you by name and provide the confidential code.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location and general condition.

Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Though it is permissive, it is not mandatory.

Research: We may disclose information to researchers when their research have been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Marketing continuity of care: We may contact you to provide appointment reminders or cancellation information.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or post marketing surveillance information to enable to enable product recalls, repairs, or replacement.

Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution: Should your son or daughter be involved with the criminal justice system, we may disclose health information necessary for your health and the health and safety of other individuals.

Law enforcement: We may disclose health information as required by law or in response to a valid court order.

Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.

The federal Department of Health and Human Services (DHHS): Under the privacy standards, we must disclose your health information to DHHS as necessary for then to determine our compliance with those standards.

Your Personal Responsibility:
It is our expectation (Institute) that you (parents), on behalf of your family, have read the complete program description given to you or reviewed on our web-site prior to your initial interview. It is our expectation that you agree with the mission, philosophy, clinical orientation, procedures and techniques referenced in these documents and furthermore agree to participate in an open, honest, consistent, and available manner. It is our expectation that you work with the clinical team throughout the entire course of care of treatment on behalf of your adolescent. This includes but is not limited to: scheduled educational and therapeutic sessions, adhering to policy and procedure regarding academic needs of your adolescent, following guidelines regarding visits, communication frequency, passes, completion of feedback questionnaires and written therapeutic assignments in a timely, complete and accurate manner