NOTICE OF PRIVACY PRACTICES
South Bay Mental Health Center, Inc.
1115 W. Chestnut St., Brockton, MA 02301
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.
If you have any questions about this Privacy Notice, please contact your counselor or agency staff; or you may contact our Privacy Officer at 800-244-4691.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights. These Notice further states the obligations we have to protect your health information. “Protected health information” means health information (including identifying information about you) we have collected from you or received from your health care providers, health plans, your employer or a health care clearinghouse. It may include information about your past, present or future physical or mental health or condition, the provision of your health care, and payment for your health care services.
We are required by law to maintain the privacy of your health information and to provide you with a notice of our legal duties and privacy practices with respect to your health information. We are also required to comply with the terms of our current Notice of Privacy Practices.
II. How We Will Use and Disclose Your Health Information
We will use and disclose your health information as described in each category listed below. For each category, we explain what we mean in general, but do not describe all authorized uses or disclosures of your health information. We do not need your authorization to use or disclose protected health information, including your psychotherapy notes, to treat you, process claims for payment for your care, or for some routine health care operations. However, we shall not use your psychotherapy notes for any other purpose, unless you give us written authorization. You may revoke, in writing, at any time, any authorization that you give us for the use of your psychotherapy notes or other protected health information.
Uses and Disclosures That May Be Made For Treatment, Payment and Operations
1. For Treatment. We will use and disclose your health information without your authorization to provide you health care and any related services. We will also use and disclose your health information to coordinate and manage your health care and related services. For example, we may need to disclose information to a case manager who is responsible for coordinating your care. However, when we make disclosures to a third party (other than your health plan) for coordination or management of your health care, we will usually obtain your written authorization prior to the disclosure. A third party is a person or entity who is not affiliated with our organization.
We may also disclose your health information without your authorization among our clinicians and other staff (including clinicians other than your therapist or principal clinician), who work at South Bay Mental Health Center. For example, our staff may discuss your care at a case conference.
In addition, with your written authorization, we will disclose your health information to another health care provider (e.g., your primary care physician or a laboratory) working outside of South Bay Mental Health Center.
2. For Payment. We may use or disclose your health information without your authorization so that the treatment and services you receive are billed to, and payment is collected from, your health plan or other third party payer. By way of example, we may disclose your health information to permit your health plan to take certain actions before your health plan approves or pays for your services. These actions may include:
¨ making a determination of eligibility or coverage for health insurance;
¨ reviewing your services to determine if they were medically necessary;
¨ reviewing your services to determine if they were appropriately authorized or certified in advance of your care; or
¨ reviewing your services for purposes of utilization review, to ensure the appropriateness of your care, or to justify the charges for your care.
For example, your health plan may ask us to share your health information in order to determine if the plan will approve additional visits to your therapist.
3. For Health Care Operations. We may use and disclose health information about you without your authorization for our health care operations. These uses and disclosures are necessary to run our organization and make sure that our consumers receive quality care. These activities may include, for example, quality assessment and improvement, reviewing the performance or qualifications of our clinicians, training students in clinical activities, licensing, accreditation, business planning and development, and general administrative activities.
We may combine health information of many of our consumers to decide what additional services we should offer, what services are no longer needed, and whether certain new treatments are effective. We may also combine our health information with health information from other providers to compare how we are doing and see where we can make improvements in our services. When we combine our health information with information of other providers, we will remove identifying information so others may use it to study health care or health care delivery without identifying specific clients.
We may also use and disclose your health information to contact you to remind you of your appointment.
Finally, we may use and disclose your health information to inform you about possible treatment options or alternatives that may be of interest to you.
4. Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. If you do not want us to provide you with information about health-related benefits or services, you must notify the Privacy Officer in writing at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. Please state clearly that you do not want to receive materials about health-related benefits or services.
5. Fundraising Activities. We may contact you about raising money for our programs, services and operations. If you do not want us to contact you for fundraising purposes, you must notify the Privacy Officer in writing at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. Please state clearly that you do not want to receive any fundraising solicitations from us.
B. Uses and Disclosures That May be Made Without Your Authorization, But For Which You Will Have an Opportunity to Object
1. Facility Directory. We maintain a limited facility directory within our inpatient residential facilities for the purpose of allowing visitors and callers to locate you and to allow clergy to determine your religious affiliation. This limited information will only be provided to individuals who ask for you by name and may include your name, location in the facility (room number, but not the type of unit), your general condition, and your religious affiliation. A statement of your general condition may, for example, state that you are stable or inform a caller of your visitation and telephone privileges, but will not disclose the diagnosis or type of treatment you are receiving.
Your religious affiliation, if provided to us upon admission, and your name and room number may be provided to a member of the clergy, such as a priest, pastor or rabbi, even if the clergy member does not ask for you by name.
You may object to being included in our facility directory upon your admission to our facilities or at later any time. If you choose NOT to be included in the facility directory, your directory information will not be provided to the clergy or to any person asking for you by name. Nor will you be identified as present on the unit. (See 2, below, for exceptions.)
If you are admitted in an emergency, the clinician responsible for your admission will determine if, in his/her professional judgment, you are capable of agreeing or objecting to being identified in the facility directory. If the clinician determines that you are not able to agree or object (e.g., you are not conscious or able to communicate clearly), that clinician will decide whether it is in your best interest to be listed in our facility directory. If the clinician decides it is in your best interest, you will be listed in our facility directory. If you later become able to make your own health care decisions, we will ask whether you agree or object to being listed in our facility directory and we will honor your expressed wishes at that time.
We do not maintain a facility directory at any of our exclusive outpatient units. If asked, we will not confirm orally, in writing or through any other medium that you are our current or former client, with the exceptions listed below under “Person’s Involved in an Individual’s Care.”
2. Persons Involved in Your Care. We may provide health information about you to someone who helps pay for your care. We may use or disclose your health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may also use or disclose your health information to a legally authorized public or private entity assisting in disaster relief efforts and to coordinate uses and disclosures for this purpose to family or other individuals involved in your health care.
We may disclose health information about you to a friend or family member who is involved in your care, provided that you agree or do not otherwise object.
But, if you are in an emergency situation, we may disclose your health information to a spouse, a family member, or a friend if we determine, in our professional judgment, that it is in your best interests and, if so, only disclose information that is directly relevant to your care.
And, if you are not in an emergency situation but are unable to make health care decisions, we will disclose your health information to:
your health care agent if we have received a valid health care proxy from you,
your guardian or medication monitor if one has been appointed by a court, or
if applicable, the state agency responsible for consenting to your care.
C. Uses and Disclosures That May be Made Without Your Authorization or Opportunity to Object
1. Emergencies. We may use and disclose your health information without your authorization in an emergency treatment situation. By way of example, we may provide your health information to a paramedic who is transporting you in an ambulance. If a clinician is required by law to treat you and your treating clinician has attempted to obtain your authorization but is unable to do so, the treating clinician may nevertheless use or disclose your health information to treat you.
2. Research. We may disclose your health information to researchers when their research has been approved by an Institutional Review Board or a similar privacy board that has reviewed the research proposal and established protocols to protect the privacy of your health information.
3. As Required By Law. We will disclose health information about you when required to do so by federal, state or local law, and, then only as much as necessary to comply with the law .
4. To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person. Under these circumstances, we will only disclose health information as required or allowed by law.
5. Organ and Tissue Donation. If you are an organ donor, we may release your health information to an organ procurement organization or to an entity that conducts organ, eye or tissue transplantation, or serves as an organ donation bank, as necessary to facilitate organ, eye or tissue donation and transplantation.
6. Public Health Activities. We may disclose health information about you as necessary for public health activities including, by way of example, disclosures to:
report to public health authorities for the purpose of preventing or controlling disease, injury or disability;
report vital events such as birth or death;
conduct public health surveillance or investigations;
report child abuse or neglect;
report certain events to the Food and Drug Administration (FDA) by a person subject to the jurisdiction of the FDA including information about defective products or problems with medications;
notify consumers about FDA-initiated product recalls;
notify a person who may have been exposed to a communicable disease or who is at risk of contracting or spreading a disease or condition;
notify the appropriate government agency if we believe an adult has been a victim of abuse, neglect or domestic violence. We will only notify an agency if we obtain your agreement or if we are required or authorized by law to report such abuse, neglect or domestic violence.
7. Health Oversight Activities. We may disclose health information about you to a health oversight agency for activities authorized by law. Oversight agencies include government agencies that oversee the health care system, government benefit programs such as Medicare or Medicaid, other government programs regulating health care, and civil rights laws.
8. Disclosures in Legal Proceedings. We may disclose health information about you to a court when a judge orders us to do so. We also may disclose health information about you in legal proceedings without your permission or a judge’s order when:
we receive a subpoena or discovery request for your health information. Normally, we will not provide this information in response to a subpoena or discovery request without notice to you or a qualified protective order;
your health information involves communications made during a court-ordered psychiatric examination;
you introduce your mental or emotional condition in evidence in support of your claim or defense in any proceeding and the judge orders disclosure of your health information;
you sue any of our clinicians or staff for malpractice or initiate a complaint with a licensing board against any of our clinicians;
the legal proceeding involves child custody, adoption or dispensing with consent to adoption and the judge orders our disclosure of your health information;
one of our social workers brings a proceeding, or is asked to testify in a proceeding, involving foster care of a child or commitment of a child to the custody of the Massachusetts Department of Social Services.
9. Law Enforcement Activities. We may disclose health information to a law enforcement official for law enforcement purposes when:
you agree to the disclosure; or
when the information is provided in response to an order of a court; or
we determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by you against yourself or another person; or
the disclosure is otherwise required by law.
We may also disclose health information about a client who is a victim of a crime, without a court order or without being required to do so by law. However, we will do so only if the disclosure has been requested by a law enforcement official and the victim agrees to the disclosure or, in the case of the victim’s incapacity, the following occurs:
the law enforcement official represents to us that (i) the victim is not the subject of the investigation and (ii) an immediate law enforcement activity to meet a serious danger to the victim or others depends upon the disclosure; and
We determine that the disclosure is in the victim’s best interest.
10. Medical Examiners or Funeral Directors. We may provide health information about our consumers to a medical examiner. Medical examiners are appointed by law to assist in identifying deceased persons and to determine the cause of death in certain circumstances. We may also disclose health information to funeral directors as necessary to carry out their duties.
11. Military and Veterans. If you are a member of the U.S. armed forces, we may disclose your health information as required by U.S. military command authorities. We may also disclose your health information for the purpose of determining your eligibility for benefits provided by the Department of Veterans Affairs.
12. National Security and Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We may also disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or so they may conduct special investigations.
13. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official.
14. Workers’ Compensation. We may disclose health information about you to comply with the Massachusetts Workers’ Compensation Law. These disclosures will usually be made only when we have received a court order or, sometimes, when we have received a subpoena for the information.
III. Uses and Disclosures of Your Health Information with Your Permission.
Uses and disclosures not described in Section II of this Notice of Privacy Practices will generally only be made with your written permission, called an “authorization.” You have the right to revoke an authorization at any time. If you later revoke your authorization we will not make any further uses or disclosures of your health information after you give us your written revocation.
IV. Your Rights Regarding Your Health Information.
Right to Inspect and Copy.
You have the right to request an opportunity to inspect or copy health information used to make decisions about your care – whether they are decisions about your treatment or payment of your care. Usually, this would include clinical and billing records, but not psychotherapy notes.
You must submit your request in writing to our Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. If you request a copy of the information, we may charge a fee for the cost of copying, mailing and supplies associated with your request.
We may deny your request to inspect or copy your health information in certain limited circumstances. In some cases, you will have the right to have the denial reviewed by a licensed health care professional not directly involved in the original decision to deny access. We will inform you in writing if the denial of your request may be reviewed. Once the review is completed, we will honor the decision made by the licensed health care professional reviewer.
B. Right to Amend.
For as long as we keep records about you, you have the right to request us to amend any health information used to make decisions about your care – whether they are decisions about your treatment or payment of your care. Usually, this would include clinical and billing records, but not psychotherapy notes.
To request an amendment, you must submit a written document to our Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691, and tell us why you believe the information is incorrect or inaccurate.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend health information that:
was not created by us;
is not part of the health information we maintain to make decisions about your care;
is not part of the health information that you would be permitted to inspect or copy; or
is accurate and complete.
If we deny your request to amend, we will send you a written notice of the denial stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with the denial. If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request.
If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that are the subject of your request.
C. Right to an Accounting of Disclosures.
You have the right to request that we provide you with an accounting of disclosures we have made of your health information. An accounting is a list of disclosures. But this list will not include certain disclosures of your health information, such as those we have made for purposes of treatment, payment, and health care operations.
To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. For your convenience, you may submit your request on a form called a “Request For Accounting,” which you may obtain from our Privacy Officer. The request should state the period for which you wish to receive an accounting. This period should not be longer than six years and not include dates before April 14, 2003.
The first accounting you request within a twelve-month period will be free. For additional requests during the same 12-month period, we will charge you for the costs of providing the accounting. We will notify you of the amount we will charge and you may choose to withdraw or modify your request before we incur any costs.
D. Right to Request Restrictions.
You have the right to request a restriction on the health information we use or disclose about you for treatment, payment or health care operations. You may also ask that any part (or all) of your health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in Section II(B)(2) of this Notice of Privacy Practices.
You must request the restriction in writing and addressed to the Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. The Privacy Officer will ask you to fill out a Request for Restriction Form, which you should complete and return to the Privacy Officer.
We are not required to agree to a restriction that you may request. If we do agree, we will honor your request unless the restricted health information is needed to provide you with emergency treatment.
E. Right to Request Confidential Communications.
You have the right to request that we communicate with you about your health care only in a certain location or through a certain method. For example, you may request that we contact you only at work or by e-mail.
To request such a confidential communication, you must make your request in writing to the Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. We will accommodate all reasonable requests. You do not need to give us a reason for the request; but your request must specify how and where you wish to be contacted.
F. Right to a Paper Copy of this Notice.
You have the right to obtain a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this Notice of Privacy Practices electronically, you may still obtain a paper copy. To obtain a paper copy, contact your counselor or agency staff; or you may contact our Privacy Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691.
V. Confidentiality of Substance Abuse Records
For individuals who have received treatment, diagnosis or referral for treatment from our drug or alcohol abuse programs, the confidentiality of drug or alcohol abuse records is protected by federal law and regulations. As a general rule, we may not tell a person outside the programs that you attend any of these programs, or disclose any information identifying you as an alcohol or drug abuser, unless:
you authorize the disclosure in writing; or
the disclosure is required by a court order; or
the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation purposes; or
you threaten to commit a crime either at the drug abuse or alcohol program or against any person who works for our drug abuse or alcohol programs.
A violation by us of the federal law and regulations governing drug or alcohol abuse is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.
Federal law and regulations governing confidentiality of drug or alcohol abuse permit us to report suspected child abuse or neglect under state law to appropriate state or local authorities.
Please see Title 42 of the United States Code (U.S.C.), Section 290dd-2 for federal law and Title 42 of the Code of Federal Regulations (C.F.R.), Part 2 for federal regulations governing confidentiality of alcohol and drug abuse patient records.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Complaint Officer at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691. To file a complaint with the U.S. Department of Health and Human Services, contact the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, (877) 696-6775. All complaints must be submitted in writing.
Your counselor or clinician or our Privacy Officer, who can be contacted at South Bay Mental Health Center, 1115 W. Chestnut Street, Brockton, MA 02301, 800-244-4691, will assist you with writing your complaint, if you request such assistance.
We will not retaliate against you for filing a complaint.
VII. Changes to this Notice
We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at our main office and at each site where we provide care. You may also obtain a copy of the current Notice of Privacy Practices by accessing our website at www.southbaymentalhealth.com, or by calling us at 800-244-4691 and requesting that a copy be sent to you in the mail or by asking for one any time you are at our office.
This Notice of Privacy Practices describes the practices of the following organizations:
South Bay Mental Health Center
South Bay Substance Abuse Counseling
South Bay Day Services
South Bay Early Intervention
All these organizations will follow the terms of this Notice of Privacy Practices. Also, these organizations may share health information with each other for treatment, payment or health care operations, as described in this Notice of Privacy Practices.
PLEASE ACKNOWLEDGE YOUR RECEIPT OF THE SOUTH BAY MENTAL HEALTH NOTICE OF PRIVACY PRACTICES BY SIGNING, DATING AND RETURNING THIS PAGE TO THE PRIVACY OFFICER OF THE SOUTH BAY MENTAL HEALTH CENTER, INC.
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