NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
Effective Date: April 14, 2003
Your Privacy is Important
Mountain Community Services understands your privacy is important. Any and all information we receive about you will
be used only to assist you. We will handle
this information only as allowed by federal / state law and agency policy.
If at any time
you believe your privacy rights have been violated, you may verbally or in writing
phone numbers to use are listed on the second page of this notice. You will not suffer change in services or
retaliation for filing a complaint.
Each time you
receive services from us, the provider makes a record of the visit. Typically, this record contains your assessment,
service plan, progress notes, diagnoses, treatment, and plan for future care or treatment.
Your Federally Defined Rights
several rights concerning your health information in the medical record that we want you
to be aware of:
- You have the right to request access to
your medical record in order to inspect, copy, amend and correct it. This process will be kept confidential. This right is not absolute. In certain situations, such as if access would
cause harm, we can deny access. You may make
this request through your Case Manager or Therapist.
- You have the right to receive at any time
an accounting of the agencys disclosure of your medical record.
- You have the right to request a
restriction with regards to the use and disclosure of your medical record. This request will be given serious consideration
and you will be informed promptly whether we will be able to use the restriction and still
offer effective services, receive payment, and maintain health care operations. Legally we are not required to abide by any
restrictions you request.
Use and Disclosure
of your Information
the agencys Consent to Services form, you are allowing us to use and disclose
necessary information about you within the agency and with business associates in order to
provide services, receive payment
of provided services, and conduct our day to day business practices.
In order to
effectively provide services, your Case Manager or Therapist may consult with various
service providers within the agency. During
those consultations health information about you may be shared.
In order to
receive payment of service provided, your health information may be sent to those
companies or groups responsible for payment coverage, and a monthly bill is sent to the
Responsible Party identified by you and noted on the financial form.
business practices, trained staff may handle your physical medical record in order to have
the record assembled, available for review by the Case Manager or Therapist, or for filing
of documentation. Certain data elements are
entered into our computer system that processes most billing, and for state statistical
reporting to Department of Mental Health, Mental Retardation, and Substance Abuse
Services. As a part of our continuous Quality
Improvement efforts to provide the most effective services, your record may be reviewed by
professional staff to assure accuracy, completeness and organization, as well as to
provide staff supervision and service planning.
Enhancing your Healthcare
programs provide the following support to enhance your overall health care:
by call or letter
recommending treatment/service alternatives
- Providing information about
health-related benefits and services that may be of interest to you
Special Circumstances for Disclosure
We are allowed
by federal and state law in certain circumstances to disclose specific health information
about you without your consent, authorization, or opportunity to agree or object. There may be documentation available to you upon
your request listing what information was disclosed, to whom, and for what reason.
- As required by law (ex: Court-ordered
- Public health activities (ex:
- Judicial and Administrative proceedings
(ex: Order from a court or administrative tribunal)
- Law Enforcement purposes (ex: reporting
of gun shot wounds; limited information requested about suspects, fugitives, material
witnesses, missing persons; witnesses criminal conduct on premises)
To avert a serious
threat to Health and Safety (ex: in response to a statement made by person served to harm
self or another)
- Children or incapacitated adults who are
victims of Abuse, Neglect, or Exploitation
- Specialized Government functions
o Military Services (ex: in response to
appropriate military command to assure the proper execution of the military mission)
o National Security and Intelligence
activities (ex: in relation to protective services to the President of the United States)
o State Department (ex: medical suitability
for the purpose of security clearance)
o Correctional Facilities (ex: to
correctional facility about an inmate)
- Workers Compensation to facilitate
processing and payment
- Coroners and Medical Examiners for the
identification of a deceased person or to determine the cause of death
detailed explanation of all situations allowed by federal and state laws is available upon
Other Uses and Disclosures of Your
Information by Authorization Only
request information to be disclosed to another party or yourself, we will respond within
state and federal law.
required to get your authorization to use or disclose your protected health information
for any reason other than treatment/services, payment, or health care operations, and
those specific circumstances outlined previously. We
use an Authorization to Release form that specifically states what information will
be given to whom, for what purpose, and is signed by you or your legal representative. You have the ability to revoke the signed
authorization at any time by
a written statement given to us to that effect, with the exception of actions already
implemented as a result of your earlier consent.
Changes to Privacy Practices
Cumberland Mountain Community Services reserves the right to
change any of its privacy policies and related practices at any time, as allowed by
federal and state law.
You will receive notice of changes either by mailing or discussion
with an agency representative or electronically or a combination of the three.
laws pertaining to privacy, please contact:
Primary Case Manager/ Clinician
Officer, Cumberland Mountain C.S.B., P.O Box 810, Cedar Bluff, VA 24609
Advocate, DMHMRSAS Satellite Office, 340
Bagley Circle, Marion, VA 24354
of Health and Human Services, Immediate
Office of the Secretary, Hubert
Humphrey Bldg., 2000 Independence Ave. SW,
Washington, DC, 20201