Confident

This 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.

This Privacy Notice has been prepared according to the Health Information Portability and Accountability Act of 1996 (HIPAA – Public Law 104-191.) The Privacy Notice tells you how Protected Health Information (PHI) about you can be created, shared, protected and maintained.

• Anything from the past, present or future about your mental or physical health or condition that is spoken, written, or electronically recorded and is;

• Created by or given to anyone providing care to you; a health plan; a public authority; your employer; your insurance company; your school or university; or anyone who processes health information about you.

• You have the right to consent to the use and disclosure of your PHI for the limited purpose of diagnoses, payment and administrative operations for your treatment.
• You have the right to authorize the sharing of your PHI for other purposes such as disability claims or forwarding to other treatment providers.
• You have the right to see and request a copy of your PHI for a nominal fee per CCC’s policy. An exception to this would be court-ordered evaluations or if your access is restricted for clear and documented treatment reasons.
• The specific PHI documented in the chart belongs to you but the clinical record itself is the sole property of CCC.
• You have the right to make a written request that CCC amend or correct your PHI. However, CCC is not required to agree with your amendments.
• You have the right to request restrictions on how CCC uses and discloses your PHI. CCC is not, however, required to agree with your requested restrictions.
• You have the right to receive an accounting of disclosures of your PHI made by CCC, including disclosures by or to a Business Associate, for purposes other than treatment, payment, and health care operations, subject to certain exceptions. This accounting obligation begins April 14, 2003 and applies prospectively.
• You have the right to request confidential communications of PHI by alternative means or at alternative locations. CCC is required to accommodate reasonable requests.
• You have the right to have a copy of this Privacy Notice. You can always get a copy of CCC’s current Privacy Notice by requesting it from your clinical service provider or CCC’s Privacy Officer.

What can be done with my Protected Health Information?

For treatment: With your consent, CCC can share your PHI with other CCC staff as needed so that you can receive the most appropriate treatment. (For example, your counselor could share with your treating psychiatrist/nurse practitioner that you are experiencing an increase in depressive symptoms. The doctor/nurse practitioner could then prescribe a medication to help you feel better.) Your PHI may also be shared with outside entities performing ancillary services related to your treatment such as lab work or ordering prescriptions.

To obtain payment: With your consent, CCC can share information about when and for what purpose you were treated so that CCC can be paid for treating you. (For example, CCC could send any required forms to your insurance company stating when and for what condition you were treated at our office for payment of services. CCC may contact your employer to verify employment status and/or release PHI to the Medicaid program, or the Mental Health & Recovery Services Board if your care is publicly subsidized.

For health care operations: With your consent, CCC may use/disclose your PHI for evaluating the quality of services provided or discloses your PHI to our accountant or attorney for audit purposes. Release of your PHI to the Multi-Agency Community Services Information System (MACSIS) and/or State agencies might also be necessary to determine your eligibility for publicly subsidized services.

Can I revoke my consent to use or disclose PHI for treatment, to obtain payment or for health care operations?

Yes, you can revoke your consent. However, you must do this in writing in order to stop the use and/or disclosure of your PHI. We are permitted to use and/or disclose your PHI based on your consent until we receive your revocation in writing. However, if you revoke your consent, we reserve the right to refuse to provide further services to you, on the basis of your refusal to allow us to share your information for purposes of treatment, payment, and health care operations.

What can be done with my Protected Health Information if I authorize its disclosure for other purposes?

With your specific authorization, CCC can share your PHI for reasons other than treatment, payment, or administrative operations. (For example, you might agree to allow CCC to share your PHI with Jobs and Family Services to obtain benefits.) Note that information used and/or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient, thus CCC cannot be held responsible for the protection of this information.

Can I revoke my authorization for release of Protected Health Information?

Yes, you can revoke your authorization; however, it must be in writing so that CCC can stop sharing your PHI. We are permitted to share your PHI based on your authorization until you revoke this consent or the Authorization for Release of Information expires.

Are there any circumstances when my information can be shared without my consent or authorization?

Yes, the minimum necessary of your PHI can be shared without your prior consent or authorization on a “need to know” basis:

Appointment Reminders: Unless you provide us with alternative instructions, we may make telephone calls to confirm appointments, leave messages on answering machines or mail billing statements or similar materials to your home.

What about other uses of my Protected Health Information?

Other uses and/or disclosures of PHI not covered by this Privacy Notice or the Federal and State laws that apply to CCC will be made only with your written permission.

What will CCC do to protect my Protected Health Information?

CCC will maintain the privacy of your PHI as required by Federal and State law.

CCC is providing you with this Privacy Notice, which contains our legal responsibilities and privacy practices regarding PHI.

All CCC employees are bound to follow the terms of the Privacy Notice currently in effect as well as CCC’s Corporate Policies & Procedures concerning the use, disclosure ad protection of your PHI. All employees sign a Confidentiality Agreement, which requires them to protect your PHI even in the event that they leave our employment.

CCC employees will have access to the minimum necessary PHI on a “need to know” basis in order to perform their job functions as outlined in their job descriptions.

CCC is obligated to monitor information flow to third parties as outlined in Business Associate Agreements or Trading Partner Agreements and will terminate these relationships if CCC becomes aware of intentional violations of the protection of your PHI by others. No disclosure of your PHI will be made without explicit and valid authorization from you other than the aforementioned exceptions outlined in this Privacy Notice.

What can I do if I have questions or want to complain about the use and/or disclosure of my Protected Health Information?

All questions and complaints about the use and/or disclosure of your PHI may be sent to:
Cambridge Counseling Center, Inc.

What can be done with my Protected Health Information?

Cambridge, OH 43725 740/435-9766 You also may file a written complaint with the Secretary of the U. S. Department of Health & Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775.

Cambridge, OH 43725
740/435-9766

You also may file a written complaint with the Secretary of the U. S. Department of Health & Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775.