Southwestern Indiana Mental Health Center - Notice of Privacy Practices

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 REVIEW IT CAREFULLY.

Who will follow this notice: This notice describes Southwestern Indiana Mental Health Center, Inc.'s (Southwestern) practices and that of: (1) any healthcare professional authorized to enter information into your Southwestern chart; (2) all employees, staff, and other personnel of Southwestern; and (3) all departments of Southwestern.

Information collected about you: We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of care and services you receive at Southwestern. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Southwestern.
Law requires us to: (1) Make sure that medical information that identifies you is kept private; (2) give you this notice of our legal duties and privacy practices with respect to medical information about you; (3) follow the terms of the notice that is currently in effect.

How we are required to disclose medical information about you: We are required to use or disclose your health information for the following purposes:

• When required to do so by federal, state, or local law.
• When we believe that it is necessary to prevent serious threat to your or another person's health & safety.
• When court ordered because you are involved in lawsuit, dispute, or criminal conduct.
• When public health reporting is required for purposes, including, but not limited to: the prevention or control of disease, injury, disability, abuse, neglect, or domestic violence; reporting of adverse effects to certain products, notifications regarding exposure to infectious disease.
• For health oversight activities including, but not limited to, audits, investigations, inspections, and licensure activities necessary for the government to monitor health care systems, government programs and compliance with various laws.
• When necessary to cooperate with court orders, to identify or locate individuals involved in a crime, to assist or locate victims of a crime and to assist with criminal investigations and other law enforcement activities
• To authorized federal officials so they can provide protection to the President or other authorized persons.

How we are permitted to disclose medical information about you. We are permitted to use and disclose medical information about you for the following purposes:

• For Treatment: includes providing health information about you to a physician or other healthcare provider who is involved with your care, whether or not they are employed by Southwestern. Example: Inpatient care provider.
• For Payment: includes use or disclosure of your health information as necessary to obtain payment for services provided to you by Southwestern or another health care provider. Example: Insurance company.
• For Healthcare operations: includes use or disclosure of your health information for quality assessment & improvement activities, reviewing the competence or qualifications of healthcare professionals, conducting training, and accreditation & licensing activities or Southwestern and certain, limited operations activities of other healthcare providers and payment sources involved in your health care.
• Sending written appointment reminders to you by mail to your address and/or conducting appointment reminders and follow up by telephoning your phone number.
• Notifying you of treatment options, services, and/or health-related benefits/services that may be of interest to you.
• We may release certain limited information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.
• We may disclose medical information about you to someone assisting in disaster relief so that your family can be notified about your status and location.

Special Situations when your medical information may be used and disclosed:

• If you are a member of the armed forces, we may release medical information about you as required by military command authorities.
• If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you: for the institution to provide you with health care, to protect your or other's health and safety; or, for the safety and security of the correctional institution.
• We may release information to Coroners, medical examiners, and Funeral directors as necessary for them to carry out their duties.
• We may release information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

You have the following rights regarding medical information:

Right to Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records. If you request a copy of the information, we will charge a fee for the costs of copying, mailing, or other supplies associated with the request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, under some circumstances you may request that the denial be reviewed. Another licensed health care professional chosen by Southwestern will review your request and the denial. The person conducting the review will be a person who was uninvolved with the original denial of your request. We will comply with the outcome of the review. Instead of providing you with a copy of your medical information, we may provide you with a summary of your medical information maintained by Southwestern. Your consent will be obtained prior to provision of such a summary and the cost incurred in generating such a summary.

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 the information is kept by or for Southwestern. You must provide a written reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by or for Southwestern; is not part of the information which you would be permitted to inspect and copy; or, is accurate and complete.

Right to an Accounting of Disclosures
You have a right to request an accounting of certain disclosures of your medical information. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the accounting. The first accounting requested by you in any twelve-month period will be provided free of charge. Any subsequent accounting requests in the same twelve-month period will be provided to you subject to your payment of a cost-based fee. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. In your request, you must tell us: what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.

Right to Request Confidential Communication
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

NOTICE: All Requests to exercise your rights described above must be submitted in writing to the manager of your assigned program or to Southwestern's Privacy Officer.

Right to a paper copy of this notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

Change to this notice
We 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 receive in the future. We will post a copy of the current notice in each of our facilities. The notice will contain on the front page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to Southwestern for treatment or health care services, a copy of the current notice in effect will be available for you.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with Southwestern's Privacy Officer or the Secretary of the Department of Health and Human Services. To file a complaint with Southwestern, contact the Manager of your assigned program or Southwestern's Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or other laws that apply to Southwestern will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of that care that we provided to you.

Additional Information
If you want more information about our privacy practices, wish to exercise your rights as described by this Notice or have other questions or concerns, please contact: Southwestern Indiana Mental Health Center, Inc., c/o Privacy Officer, 415 Mulberry Street, Evansville, Indiana 47713, Telephone: (812) 436-4232.

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