NOTICE OF PRIVACY PRACTICES
This notice describes how your health information may be used and disclosed and how to get access to this information. Please review it carefully. The privacy of your health information is important to Child & Family Services of Southwestern Michigan, Inc.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect on 4/14/2003 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at anytime, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and behavioral health care operations.
Treatment: We will not disclose any health care information about you without prior written authorization. Your authorization for release of information must be in written form and will have a designated expiration date. You are also free to withdraw consent at any time. You have the right to a full description of all information being released about you with your consent. The only exceptions to this rule include the following:
If you threaten to harm yourself or others and your therapist believes that there exists a credible threat.
If a minor child discloses that they have been abused and/or neglected, we are required by law to file a FIA Form 3200 and to call the Michigan Family Independence Agency and make a verbal report.
If you commit a crime or threaten to harm an employee of The Avenue.
Payment: We may use and disclose your health information to obtain payment for services we provide you.
Healthcare Operations: We may use and disclose your health information in connection with our behavioral healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of our professional staff, evaluating your therapist and our agency performance, conducting training programs for staff, accreditation, certification, and licensing or credentialing and referral activities. We may receive referral information regarding your health care by fax or phone. Referral and treatment communications may be discussed by telephone with referral agencies and with your assigned worker. We will strive to keep this information confidential. Furthermore, we have trained all of our staff in privacy and confidentiality.
To Your Family and Designated Others: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member or other person to the extent necessary to help with your healthcare or with payment for your care, but only if you sign a written authorization for us to do so. We will not, however, leave a message on an answering machine without your written permission to do so. Likewise, we will not leave messages about your behavioral health care with strangers not known to us. We will not divulge that you are a patient at The Avenue without your written permission if someone telephones us to ask if you are a patient here. Even if they say they are related to you, we will not disclose information without your written permission.
Marketing Behavioral Health Services: We will not use your health information for marketing communications without your authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Access: You have the right to look at your health information, with limited exceptions. If you request to look at your patient record, you will be provided with our procedure regarding this request.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last six years, but not before April 14, 2003. If you request this accounting more than once in a twelve month period, we may charge you a reasonable cost based fee for responding to these additional requests.
Restrictions: You have the right to request that we place additional restrictions on our use of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in mandatory reporting requirements or emergency).
Amendment: You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) We may deny your request under certain circumstances.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, or in response to a request you made to amend or restrict the use of your health information, or to have us communicate with you by alternate means, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint upon your request.
Contact Privacy Officer:
Judy Miedema, Director of Human Resources
Telephone: 269-925-1725 Fax: 269-925-1730
Address: P.O. Box 8789, Benton Harbor, MI 49023-8789