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| 625 W. Washington Ave.• Madison, WI 53703-2637 • Ph:608-280-2700 • Fax:608-280-2707 | |
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NOTICE OF PRIVACY PRACTICES
Protected
Health Information as it relates to
Mental Health & Alcohol and Other Drug Abuse Services
provided by
Mental Health Center of Dane County, Inc.
Effective April 14, 2003
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The Mental Health Center of Dane County, Inc. (also referred to in this
document as “MHCDC,” “Mental Health Center” or
the “Center”) is committed to protecting the privacy of health
information about you and the services you receive at the Mental Health
Center. Your privacy rights and our responsibilities are governed under
provisions of State and Federal Law, including but not limited to:
- Sec. 51.30, Wisconsin Statutes
- HFS 92, Wisconsin Administrative Code
- 42 Code of Federal Regulations, Part 2, Confidentiality of Alcohol & Drug Abuse Patient Records
- 45 Code of Federal Regulations, pts 160 & 164, Health Insurance Portability/Accountability Act of 1996 (HIPAA)
The Mental Health Center is required by law to:
- Maintain the privacy of your health information
- Provide you with this notice of our duties and practices with respect to your health information; and
- Abide by the terms of this notice.
In general, the Mental Health Center must obtain your written consent
before giving anyone outside the Center information which identifies you
as someone who has applied for or received services at the Center or before
disclosing any personally identifiable information from your treatment
record. You may revoke any such authorization at any time, except to the
extent that information has already been shared. This can be done by giving
written notice to your MHCDC service provider(s) or to the Center’s
Records Department.
The following page lists exceptions in which information about you may
be disclosed without your consent. In all cases—with or without
consent—information given will be limited to that information needed
to meet the purpose for the disclosure and/or to the extent provided for
by law.
USES AND DISCLOSURES
REQUIRED OR PERMITTED
WITHOUT YOUR CONSENT
Within the Mental Health Center—Without Consent
The Mental Health Center is made up of a number of clinical programs and
administrative departments staffed by employees, students and volunteers.
Your health information may be shared across these programs, departments
and staffing categories for purposes of treatment, payment and health
care operations, but this is done only where there is a need to know the
information. For example, medical staff at MHCDC may need to consult with
your case manager about prescribing medications, program assistants may
need access to information to send you an appointment reminder or a description
of new services, management and executive staff may access your health
information for purposes of evaluating services or the performance of
your health care provider, etc.
Outside the Mental Health Center—Without Consent
To Avert a Serious Threat to Health or Safety: As required
or permitted by law and standards of ethical conduct, we may release your
health information to the proper authorities if we believe, in good faith,
that such release is necessary to prevent or minimize a serious and approaching
threat to your health or safety or to the health or safety of the public.
Examples might include reporting of child abuse, a threat made to harm
a specific individual, sharing of information with physicians in a hospital
emergency room, etc.
Business Associates: Certain services (for example, lab
testing, pharmacy, legal services, etc.) are performed through contract
with outside persons or organizations known as “Business Associates.”
Your health information may be shared with one of these business associates
as it is necessary to the service they provide for us. The Mental Health
Center signs an agreement with these business associates that obligates
them to appropriately safeguard privacy of the information.
For Payment: The Mental Health Center may need to submit a bill identifying you, your diagnosis and treatment provided to an insurer or other agency paying for your mental health services (for example, Medicare or Medicaid, grant funders, private insurance, etc.). If you are receiving alcohol or other drug abuse treatment, however, your signed release is required to release information for payment purposes.
Health System Oversight Activities: Certain information
may be shared with government agencies who provide funding to or oversight
of the Mental Health Center’s services. Examples of such agencies
include the Wisconsin Department of Health and Family Services and the
Dane County Department of Human Services. Purposes for disclosing the
information might include service coordination, financial or program audits,
program certification, death investigation, etc.
Research: The Mental Health Center may use or disclose
information about you for research purposes under conditions that meet
the stringent requirements of both State and Federal law and the Center’s
Research Committee. In most cases, however, the Center will first remove
information that personally identifies you or seek your approval to participate
in a research study before sharing the information.
Judicial Proceedings: The Center may disclose information
in response to a specific legal proceeding, court order or other legal
process, as stipulated by law. For example, law enforcement officers often
consult with the Center’s Emergency Services staff in the process
of an emergency detention.
Crime on Premises or Against Program Personnel: In certain
circumstances, the Mental Health Center may disclose limited information
to law enforcement officers when a client commits or threatens to commit
a crime at any Mental Health Center facility or against MHCDC staff.
Family Members: Limited information may be shared with your spouse, parent, adult child or sibling, but only if MHCDC treatment staff have verified that the family member is directly involved in providing or monitoring your treatment.
YOUR HEALTH INFORMATION RIGHTS
You have the right to:
Receive Confidential Communications: You have the right to request that we communicate with you by alternative means or at an alternative location. For example, you may ask that we phone you at work rather than at home. We will try to accommodate reasonable requests.
Access your Treatment Record: You have the right to inspect (within one working day) and obtain (within five working days) a copy of your treatment record, except for specific documents where access is prohibited by law. This information will be provided at no cost to you for the first copy. Requests for additional copies may result in a customary fee to cover the cost of duplication.
Amend your Treatment Record: You have the right to request an amendment to your treatment record if you believe information in the record is incorrect or incomplete. If the staff person working with you disagrees with the requested amendment, you may submit a written request to the Center’s Medical Director specifying the information you would like to have changed and the reason for the change. Your request will be granted or denied by the Medical Director within 30 days. You will receive either a copy of the information as amended in your record or a written explanation of why the request was denied. If the request is denied, you have the right to insert a statement in the record disputing the accuracy or completeness of the information which was not changed. This statement will become part of your treatment record.
Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information for payment of services or the Center’s service related operations. The Center is not obligated to agree to your request but will give every reasonable request careful consideration. For example, if your neighbor works at the Center as a transcriptionist, we may be able to have someone else type any information dictated by a clinician for your treatment record.
Obtain an Accounting of Disclosures: You have the right to an accounting of disclosures of your health information made by MHCDC. This accounting will list the date of each disclosure, a brief description of information disclosed and the reason for disclosure. The first accounting in any 12-month period is free; you may be charged a reasonable fee for any additional accounting requested by you within the same 12-month period.
Request a Paper Copy of this Notice: If you received this “Notice of Privacy Practices” electronically, you may request that the Mental Health Center provide you with a paper copy.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a
complaint by contacting the Mental Health Center’s Client Rights
Specialist at (608) 280-2700. You may also file a complaint with the Secretary
of the U.S. Department of Health and Human Services in Washington, D.C.,
in writing, within 180 days of the violation. There will be no retaliation
against you for filing a complaint.
FOR FURTHER INFORMATION ABOUT THIS NOTICE
Contact:
Linda Keys, Program Director
Mental Health Center of Dane County, Inc.
625 West Washington Avenue, Madison, WI 53703
(Phone) 608-280-2700 • (Fax) 608-280-2707
The Mental Health Center must
comply with the provisions of this notice, although we reserve the right
to change our privacy practices and the terms of the notice and to make
the revised notice effective for all protected health information maintained
by MHCDC. The Center will promptly revise and distribute its notice, during
a client contact with the Center or by mail, whenever a substantial change
in any of its privacy practices is made.
MHC-HIPAA: 04/14/03