ROOTS COUNSELING SERVICES
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.
Roots Counseling Services is committed to protecting the privacy of your health information. This Notice of Privacy Practices explains how we may use or release your medical information and outlines your privacy rights. Health information used or released may include information that appears on treatment, payment, and other records used to make decisions about you in the course of providing care, services or other benefits.
YOUR HEALTH INFORMATION RIGHTS
YOU HAVE THE RIGHT TO SEE OR COPY YOUR HEALTH INFORMATION
You have the right to see or copy your health information. You have a right to request that copy be provided in electronic form or format (e.g., PDF saved onto a CD). If the form and format are not easily created, then we will work with you to provide it in a reasonable electronic form or format. Your request must be in writing and should be submitted to Roots Counseling Services administrative staff. We may charge you a reasonable fee for costs associated with your request. We are not required to allow you to see or copy psychotherapy notes, or information prepared for use in legal actions or proceedings.
CORRECT INFORMATION YOU BELIEVE TO BE INCORRECT OR INCOMPLETE
If you believe that your medical information is incorrect or incomplete, you may submit a request to us asking that your information be changed. Your request must be in writing and must include the reason(s) why you believe a change should be made. We are not required to approve your request. We will notify you if we approve your request, or explain the reason(s) for our decision if we deny your request.
REQUEST A LISTING OF WHO WAS GIVEN YOUR INFORMATION AND WHY
You have the right to request a list of disclosures of your medical information that we made in compliance with federal and state law. Upon your request, we will provide you with a list that includes the date we released health information, the name of the person or organization, a brief description, and the reason for the disclosure. We will provide one list free of charge per year. Contact the facility you received service or treatment from for assistance.
REQUEST RESTRICTION(S) ON HOW WE USE OR SHARE YOUR INFORMATION
You have the right to request a restriction or limitation on how we use or release your medical information for purposes of treatment, payment or operations. We may choose not to comply with a restriction request, unless you or another person have paid for services out-of-pocket, in full, and you request that we do not disclose medical information related solely to those services to a health plan. We ask that you complete a request form from administrative staff and submit it for evaluation. We will contact you if we deny your request.
REQUEST CONFIDENTIAL COMMUNICATION(S)
You may ask that we communicate with you about health matters in a certain way or at a certain location. For example, if you are an outpatient client, you could request that we contact you at your workplace or via email. We will attempt to accommodate all reasonable requests. To request an alternative method of communication, you must specify how or where you wish to be contacted.
REQUEST A PAPER COPY OF THIS NOTICE
You have the right to request a paper copy of this Notice from us at any time. Please contact administrative staff to request a paper copy. You may also view and download a copy of this Notice from our web site. The address is: www.rootsmke.org
NOTIFIED OF A BREACH
Roots Counseling Services is required by law to maintain the privacy of your information and provide you with notice of its legal duties and privacy practices with respect to your information and notify you following a breach of unsecured protected health information.
HOW YOUR HEALTH CARE INFORMATION MAY BE USED WITHOUT YOUR WRITTEN PERMISSION
Your medical information may be used and released by us for purposes of treatment, payment for services, administrative and operational purposes, and to evaluate the quality of the services that you receive. Because we provide a range and variety of health care and services, not all types of uses and releases can be described in this document. We have listed some common examples of permitted uses and releases below.
We may share your medical information when we coordinate services you may need, such as clinical examinations, therapy, nutritional services, medications, hospitalization or follow-up care. For example, your medical information may be given to a pharmacist when you need a prescription filled.
We may release your medical information for billing purposes to collect payment for service and treatment that you receive. For example, your medical information may be shared with your health plan to provide billing information for services that you have received. We may also share your medical information with government programs such as Medicaid, Medicare or the Indian Health Services to coordinate benefits and payment.
FOR HEALTH CARE OPERATIONS
We may use and release your medical information to ensure that the services and benefits provided to you are appropriate and high quality. For example, we may use your medical information to evaluate our treatment and service programs. We may combine medical information about many individuals to research health trends, to determine what services and programs should be offered, or whether new treatments or services are useful.
HEALTH INFORMATION EXCHANGE
We may make your medical information available electronically through an information exchange service to other health care providers, health plans and health care clearinghouses that request your information. Participation in information exchange services also lets us see their information about you.
TO GOVERNMENT AGENCIES PROVIDING BENEFITS OR SERVICES
We may release your medical information to government agencies or programs that provide services or benefits to you if the release is necessary to coordinate the delivery of your services or benefits.
FOR PUBLIC HEALTH
We may release your medical information to local, state or federal public health agencies, subject to the provisions of applicable state and federal law. For example, we may disclose information for the following types of activities:
- To prevent or control disease, injury or disability or to keep vital statistics records such as data about births and deaths;
- To notify social service agencies that are authorized by law to receive reports of abuse, neglect or domestic violence, and;
- To report reactions to medications or problems with products to the Federal Food and Drug Administration.
FOR HEALTH OVERSIGHT
We may share your medical information with the Department of Health Services and with other agencies for oversight activities as required by law. Examples of these oversight activities include audits, inspections, investigations and licensing activities.
Your medical information may be disclosed to fulfill a requirement by law or law enforcement agencies. For example, medical information may be used to identify or locate a missing person.
COURT OR OTHER HEARINGS
Your medical information may be disclosed to comply with a court order.
We may release your medical information for research projects that have been reviewed and approved by an institutional review board or privacy board to ensure the continued privacy and protection of the medical information.
FOR LAWSUITS AND DISPUTES
If you are involved in a lawsuit or dispute, we may release your medical information about you in response to a legal order. We may also release your medical information in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute, but only if they have made an effort to tell you about the request or to obtain an order protecting the medical information requested.
TO AVERT A SERIOUS THREAT TO HEALTH OR PUBLIC SAFETY
We may release your medical information if it is necessary to prevent or lessen a serious threat to your health and safety, the health and safety of another person, or to the general public.
FOR NATIONAL SECURITY AND PROTECTION OF THE PRESIDENT
We may release your medical information to an authorized federal official or other authorized person for the purpose of national security, providing protection to the President, or to conduct special investigations as authorized by law.
TO CORRECTIONAL INSTITUTIONS
If you are an inmate of a correctional institution or in the custody of a law enforcement officer, we may release your medical information to the correctional institution or law enforcement officer, provided the release is necessary to provide you with health care, protect your health and safety, the health and safety of others, or for the safety and security of the correctional institution.
SPECIALIZED GOVERNMENT FUNCTIONS
We may release your medical information to the government for specialized government functions. For example, your medical information may be disclosed to the Department of Veterans Affairs to determine eligibility for benefits. If you do not object and the situation is not an emergency and disclosure is not otherwise prohibited by other laws, we are permitted to release your information under the following circumstances:
- To Individuals Involved In Your Care – We may release your medical information to a family member, other relative, friend or other person whom you have identified to be involved in your health care or the payment of your health care;
- To Family – We may use your medical information to notify a family member, a personal representative or a person responsible for your care, of your location, general condition or death, and;
- To Disaster Relief Agencies – We may release your medical information to an agency authorized by law to assist in disaster relief activities.
REQUIRED BY LAW
In addition to the ways listed previously, your medical information may be disclosed when required by law.
APPLICABILITY OF MORE STRINGENT STATE LAW
Some of the uses and disclosures described in this notice may be limited in certain cases by applicable state laws that are more stringent than federal laws, including disclosures related to mental health and substance abuse, developmental disability, alcohol and other drug abuse (AODA), and HIV testing.
We are required by state and federal law to maintain the privacy of your medical information. Release of your medical information for reasons other than those necessary for treatment, payment or operations, as outlined in this Notice, or as otherwise permitted by state or federal law, will be made only with your written authorization. You may, revoke, in writing, your authorization at any time. If you revoke your authorization, we will no longer release your medical information to the prior authorized recipient(s), except to the extent that we previously relied on your original authorization to release your information. We are required to abide by the provisions of this Notice. We, however, reserve the right to revise this Notice. We also reserve the right to make the revised Notice effective for the medical information we that we maintain. We will post a current copy of this Notice at our treatment site and on our website. In addition, you may ask for a copy of our current privacy practices whenever you visit our facility for treatment or to receive health care services.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
Please send your written complaints about this Notice, how we handle your medical information, or if you believe your privacy rights have been violated to the administrative staff. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to the Privacy Officer, Department of Health and Human Services, Region V. Office of Civil Rights, 233 North Michigan Avenue, Suite 240, Chicago, Ill 60611. If a complaint relates to your privacy rights while you were receiving treatment for mental illness, alcohol or drug abuse or a developmental disability you may also file a complaint with the staff or administrator of the treatment facility or community mental health program. There will be no retaliation against you in any way for filing a complaint.
Effective Date of This Notice: May 1, 2015
Privacy Officer: Trevor Nettles
Roots Counseling Services
1681 N Prospect Ave.
Milwaukee WI 53202