NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
Verde Valley Guidance Clinic (VVGC) and Northern Arizona Regional Behavioral Health Authority (NARBHA) understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. Verde Valley Guidance Clinic and NARBHA create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices applies to all of the records of your care generated and/or maintained by Verde Valley Guidance Clinic and NARBHA, including the following people and organizations:
This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
Verde Valley Guidance Clinic and NARBHA are required by law to:
NOTE: In reading this Notice, “you” also refers to “your medical care decision maker”.
The following information describes different ways we use and disclose medical information. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information. If you are receiving services for the evaluation or treatment of substance abuse or communicable diseases, including Human Immunodeficiency Virus (HIV) conditions, specific rules apply to the use and disclosure of information related to those services. Please refer to the sections entitled Substance Abuse Health Information and Communicable Disease Related Information for those rules.
to certain psychotropic medications. The psychiatrist may need to contact your primary care physician to obtain that information. Different departments or organizations within Verde Valley Guidance Clinic may also share information about you in order to coordinate the different services you need, such as medications, therapy, or case management. If you are in jail, your medical information may be shared with necessary medical personnel to coordinate your ongoing care. Verde Valley Guidance Clinic may request your signed authorization for some treatment disclosures as a way to inform and involve you with the course of your treatment, although it is not required in all cases.
SUBSTANCE ABUSE HEALTH INFORMATION. The confidentiality/privacy of alcohol and drug abuse member records related to the diagnosis, treatment, referral for treatment or prevention, is protected by federal law and regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3) and regulation (42 C.F.R. part 2). Generally, a substance abuse program may not disclose to anyone outside the program that a member attends the program or disclose any information identifying a member as an alcohol or drug abuser, unless:
COMMUNICABLE DISEASE & HIV RELATED INFORMATION. Communicable disease related information, including HIV-related information, is kept strictly confidential and released only in conformance with the requirements of state law (A.R.S. §§ 36-664 and 36-665). A general authorization for the release of medical or other communicable disease related information is not sufficient to release HIV-related information. A written authorization must specifically indicate that it is for the release of confidential HIV-related information.
For medical information, other than substance abuse health information and communicable disease related information, which are discussed above, the following special circumstances apply. Federal and state laws allow or require Verde Valley Guidance Clinic and NARBHA to disclose medical information other than substance abuse, communicable disease or HIV information about you without your written authorization in certain special situations, if they occur.
Public Health Risks (Health and Safety for you and/or others). We may disclose medical information about you for public health activities, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:
Health Oversight Activities. We may disclose medical information about you to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, accreditation and licensure. These activities are necessary for the government or other agencies to monitor the behavioral health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or legal action, we may disclose medical information about you in response to a court or administrative tribunal order, or pursuant to a subpoena if done in accordance with Arizona law.
Law Enforcement. We may release medical information about you if asked to do so by a law enforcement official:
Coroners, Medical Examiners and Funeral Directors. We may release information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release medical information about members to funeral directors as necessary to carry out their duties.
As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law, and/or as required for national security or protective services.
Right to Access: You have the right to insect and copy medical information that may be used to make decisions about your care. Usually, this includes progress notes, evaluations/assessments, treatment plans, and billing information, but is not limited to only that information.
To inspect and obtain a copy of your medical information, contact the Verde Valley Guidance Clinic Privacy Officer. If you request a copy of the information, you may receive one copy at no cost each year. For any additional copies during the same year, you may be charged a fee for the costs of copying, mailing, or other supplies associated with your request.
Your request to inspect and copy your information may be denied in certain very limited circumstances. If you are denied access to any part of your medical information, you may request that the denial be reviewed. Information regarding how to initiate that review process will be provided in writing at the time of any denial of your access to the information.
Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as your medical information is kept by Verde Valley Guidance Clinic and NARBHA.
To request an amendment, your request must be made in writing and submitted to the VVGC Privacy Officer. You must provide a reason that supports your request. We may deny your request if you ask us to amend information on that:
Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you to others. The accounting does not include information disclosed based on your written permission or as a part of treatment, payment, or health care operations. To request this accounting, you must submit your request in writing to the VVGC Privacy Officer. Your request must state a period of time for the accounting that may not be longer than six years and may not include dates before March 1, 2003.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. We are not required to agree to your request, particularly if it is not in accordance with Arizona or Federal law. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the VVGC Privacy Officer. In your request, you must tell us what information you want to restrict, and to whom you want the restriction to apply.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location if you believe that you will be otherwise endangered. For example, you can ask that we only contact you at a certain telephone number or address. To request confidential communications, you must make your request in writing to the VVGC Privacy Officer. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Paper Copy of the Notice: You have the right to a paper copy of this Privacy Notice. You may ask us to give you a copy of the Privacy Notice at any time by requesting a copy from the VVGC Privacy Officer, VVGC Front Desk Reception, or the NARBHA Privacy Officer.
Verde Valley Guidance Clinic and NARBHA reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we will receive in the future. NARBHA will post a copy of the current notice at its main office and on its website. Verde Valley Guidance Clinic will post the notice at all of their service sites and provide a copy at intake and distribute copies to open members at their next appointment. The notice will contain the effective date at the bottom of each page. Verde Valley Guidance Clinic and NARBHA will make you aware of any revisions by posting a revised notice in all the above locations.
If you believe your privacy rights have been violated, you may contact or file a complaint with the Verde Valley Guidance Clinic Privacy Officer, 8 E Cottonwood St., Cottonwood AZ 86326 or with the Privacy Officer at Northern Arizona Regional Behavioral Health Authority, 1300 S. Yale St., Flagstaff, Arizona 86001. For further questions, you may contact the Verde Valley Guidance Clinic Privacy Officer at 1-928-634-2236 or the NARBHA Privacy Officer at 1-800-640-2123. If we cannot resolve your concern, you also have the right to file a written complaint with the United States Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to Verde Valley Guidance Clinic and NARBHA will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered in your written authorization. Verde Valley Guidance Clinic and NARBHA are unable to take back any disclosures already made with your authorization, and are required to retain our records of the care and services we provided to you.
Privacy Notice Effective 4/14/2003
Implemented:3/03/03 revised: 3/19/03
Revised: 11/1/04—Effective Date: 11/1/04 Page 5 of 5