BREAKTHROUGH HOUSE, INC.
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!
If you have any questions about this notice, please
contact:
Glen Yancey
Executive Director
603 SW Topeka Boulevard, Suite 100
Topeka, KS 66603-3230
Phone: (785) 232-6807
Email: GYancey@breakthroughhouse.org
INTRODUCTION
Protecting the privacy and confidentiality of your Protected Health
Information (PHI) is very important at Breakthrough House. Protecting
your information and providing this notice is mandated by federal
and state law. In order for Breakthrough House to provide mental
health services to you, we must obtain, 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. Any individual who is unable to read or comprehend
the notice as written will be offered the opportunity to have the
notice read to them. We must give you notice of our legal duties
and privacy practices concerning your private information, including:
•We must protect and keep private PHI that we have
collected about your past, present, or future mental health condition
and the mental health care we provide to you or payment for your
mental care;
• We must explain how, when, and why we disclose your private
health information;
• We must give you this notice of our legal duties and privacy
practices with respect to your PHI and make a good faith effort
to obtain your acknowledgement of receipt of this notice;
• For participants under the age of 18 or adults who have
a legal guardian, we must offer this notice to the parent or legal
guardian who is responsible for consenting to their medical care;
and
• We must abide by the terms of this notice.
As a Breakthrough House participant, you have legal rights about
your private information and these rights will be explained below.
How Breakthrough House Protects Your Personal Information
We are committed to protecting the confidentiality of your
medical information. We have adopted policies and procedures that
require our employees and business associates to treat you PHI as
private. We limit access to your PHI to those who need it to do their
jobs. All employees are trained on appropriate procedures regarding
confidential information, and we monitor our privacy practices on
a consistent basis. We protect private information of former participants
the same way we protect the private information of current Breakthrough
House participants.
Personal Information Gathered by Breakthrough House
Breakthrough House staff will ask you for personal information such
as your name, address, date of birth, social security number, gender,
and mental health information to verify that you are eligible to receive
our services, etc. Any information that can be used to identify you
is considered protected health information (PHI).
Effective Date: April 14, 2003
Question: Do you have to
answer the questions we ask?
Answer: Generally, the law does not say
that you have to give us information. However, if you do not give
us some information, we may not be able to provide you with services.
How and Why Breakthrough House Collects Your Information
Breakthrough House staff will ask for private information during the
intake process. We will always get your written permission before
we ask others and before releasing your personal information unless
we are required to do so. In addition to gathering information at
the time of intake, Breakthrough House periodically (at least every
three years) needs to gather new or updated information in order to
provide you with the highest quality of services. In addition, we
create a record of the care and services that you receive from Breakthrough
House, including any information that we obtain from you. Such information
may include work on treatment plan goals, symptoms, changes in your
life, and information from other community service providers who are
involved in your care and with whom you have signed a release. This
also includes billing of services. We need these records to provide
you with quality care and comply with certain legal requirements.
This notice applies to all of the records generated only by Breakthrough
House, Inc. personnel. IN all cases, Breakthrough House must adhere
to KSA 65-5603 which addresses confidential communications.
Question: What kind of information is
included in this notice?
Answer: This notice covers all information
that could be used to identify you, including: name, address,
telephone number, social security number, dates (except for years
such as birth date, intake date), email addresses, medical records
numbers, member numbers, account numbers, certificate/license
numbers, biometric identifiers such as face photographs, finger
prints, and any other unique identifying number, characteristic,
or code.
The technical term for this information is Protected Health Information
or PHI. In order for this notice to be easily understandable, this
notice also refers to such terms as personal information, medical
information, etc., and all of which are referring to PHI.
YOUR RIGHTS REGARDING YOUR 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 and services provided
by Breakthrough House.
To inspect and copy medical information that may be used to make
decisions about you, you must submit your request in writing to
the executive director or program director as appropriate. If you
request a copy of the information, we may charge a fee for the costs
of copying, mailing, or other supplies and services associated with
your request.
In accordance with Kansas 65-5603 Confidentiality Statutes, certain
portions of your record may not be available for your review. These
include sections which would deem to be injurious to your welfare
or would violate confidentiality of someone else.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information,
you may request that the denial be reviewed. Another licensed health
care professional chosen by Breakthrough House will review your
request and the denial. The person conducting the review will not
be the person who denied your request. We will comply with the outcome
of the review.
Right to Amend
If you believe 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 Breakthrough House.
To request an amendment, your request must be made in writing and
submitted to the executive director, or program director as appropriate.
You must provide a reason to support 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 Breakthrough
House;
• Is not part of the information that you would be permitted
to inspect and copy; or
• Is accurate and complete.
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, with certain exceptions specifically defined by law.
An accounting will not include internal uses of information for
treatment, payment or operations, or disclosures made to family
with appropriate releases.
To request this list of accounting of disclosures, you must submit
your request in writing to the executive director, program director,
or as appropriate. Your request must state a time period which may
not be longer than six years and my not include dates before April
14, 2003. Your request should indicate in what form you want the
list (for example, on paper, electronically). The first list you
request within a 12-month period will be free. For additional lists,
we may charge you for the costs of providing the list. 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 of Disclosures
You have the right to request a restriction or limitation on the
medical information that 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, like
a family member or friend.
• We are not required to agree to your request. If we do
agree, we will comply with your requests unless the information
is needed to provide emergency treatment.
To request restrictions, you must make your request in writing
to the executive director or program director as appropriate. In
your request, you must tell us:
1) what information you want
to limit;
2) whether you want to limit
our use, disclosure, or both; and
3) to whom you want the limits
to apply, for example, disclosures to your spouse.
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. For example,
you can ask that we only contact you at work or by mail. To request
confidential communications, you must make your request in writing
to the executive director or program director, as appropriate. 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.
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. Even if you have
agreed to receive this notice electronically, you are still entitled
to a paper copy of this notice. To obtain a paper copy of this notice,
contact Pat Vega, Privacy Officer, Breakthrough House, Inc., 603
SW Topeka Boulevard, Suite 100, Topeka, KS 66603-3230, (785) 232-6807.
Question: What does Breakthrough House
do with my private information?
Answer: Breakthrough House may use your
private information in a variety of ways including coordinating
and providing services, billing for services provided, handling
complaints, and grant and contract compliance. Breakthrough House
also uses information about you for management and administrative
functions that include employee training, supervision of staff,
legal consultation, accounting, auditing and statistical reports,
and program evaluation. Read on for a more detailed description
of how we use this information.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
There are a number of purposes for which it may be necessary for
us to use or disclose your personal health information. For some
of these purposes, we are required to obtain your consent. In a
limited number of circumstances, we will be authorized by law to
disclose your health information without your consent or authorization.
The following categories describe different ways that we are permitted
to use and disclose your medical information without a specific
authorization from you:
A. Uses and Disclosures
of Your Personal Health Information for Purposes of Treatment, Payment,
and Health Care Operations
• Mental Health Treatment We may use or disclose information
about you to provide and manage your mental health care. This
may include communicating with other providers regarding your
treatment and coordinating and managing the delivery of mental
health services with others. For example, we may use or disclose
health information about you when you need a referral to other
providers or services. We may disclose medical information about
you to other service providers within Breakthrough House such
as work unit coordinators, attendant care workers, residential
staff, and Compeer if you are involved in these services. Different
departments of Breakthrough House also may share information about
you in order to coordinate your services. We will disclose medical
information about you to people outside Breakthrough House only
with appropriate signed releases from you. For example, changes
in your medical or mental status may be disclosed to your doctor
or therapist.
• Appointment Reminders and Other Contacts We may use your
private information to contact you with reminders about your appointments,
other programs you may want to consider, or other services that
may be of interest to you. We may use your private information
to contact you if you become inactive and invite you back to our
program(s).
• Payment We may use and disclose medical information about
you so that the treatment and services you receive at Breakthrough
House may be billed. For example, we may need to give your health
plan information about attendant care or psychosocial treatment
you received at Breakthrough House so that Medicaid will pay us
for the service. The information on or accompanying the bill may
include information that identifies you, as well as your diagnosis
and services you received.
• Health Care Operations We may use and disclose medical
information about you to allow us to perform business functions.
These uses and disclosures are necessary to run Breakthrough House
and make sure that all participants receive quality care. For
example, we may use medical information to help us train staff
and conduct quality improvement activities. Breakthrough House
provides support for the training of health care practitioners.
In the course of collecting and tabulating attendance information
for the purposes of billing and tracking attendance, other Breakthrough
House participants will see some personal information about you
including name and member number. We may also disclose your information
to consultants and other business associates who help us with
these functions. We may disclose to the local community mental
health center (Valeo Behavioral Health Care) information regarding
local and state hospitalizations, residential status, employment,
and education status. This information is then forwarded to the
Mental Health Consortium for removal of identifying information
and results tabulation. Results are then made available to Mental
Health Substance Abuse Treatment Report for service evaluation.
We may also disclose your records to the local mental health authority
(Valeo Behavioral Health Care) or Kansas Department of Social
and Rehabilitation Services (SRS) to ensure that we have acted
consistent with state guidelines regarding your care and billing.
• Fundraising As part of our health care operations, we
may ask your permission to use or disclose your information to
raise money for our organization as well as for awareness.
• Research Under certain circumstances, we may use and disclose
medical information about you for research purposes. Breakthrough
House may disclose medical information about you to people preparing
to conduct a research project, for example, to help them look
for participants with specific medical needs, so long as the medical
information they review does not leave Breakthrough House. We
will always ask for your specific permission if the researcher
will have access to you name, address, or other information that
reveals who you are, or will be involved in your care at Breakthrough
House.
• Service Coordination As part of our health care operations,
for the purpose of celebrating individual Breakthrough House participant
accomplishments, you name, phone, and/or other PHI may be posted
in one or more of the Breakthrough House facilities. From time
to time there will be special drawings, outings, and trips where
sign up sheet may be posted. Breakthrough House participants who
put their name on the sheet acknowledge that any persons including
other Breakthrough House participants, staff, and the general
public may be able to see your PHI. In these instances, alternative
means of signing up will be posted.
B. Uses and Disclosures
of your Health Information that Require your Opportunity to Agree
or Object
In the following instances, we will provide you with the opportunity
to agree or object to our use or disclosure of your health information:
• Persons Involved in your Care We may, using our best
judgment, disclose to a family member, other relative, close personal
friend, or any other person identified by you, mental health information
relevant to that person’s involvement in your care or payment
related to your care.
• Notification to Others We may, in some instances, disclose
health information about you to a family member, a personal representative
or another person responsible for your care in order to notify
such person about your current location or general condition.
C. Use and Discloses Authorized
by Law
Under certain circumstances, we are authorized by law to use or
disclose your private information without obtaining a consent or
authorization from you. These may include when the use or disclosure
is:
• Required by Law We will disclose medical information
about you when required to do so by federal, state, or local law.
• Necessary for Public Health Activities For example, when
reporting to public health authorities the exposure to certain
communicable diseases or risks of contracting or spreading a disease
or condition.
• To Avert a Serious Threat to Health or Safety We may use
and disclose medical information about you when necessary to prevent
a serious threat to your health and safety, or the health and
safety of the public, or another person.
• Public Health Risks We may disclose medical information
about you for public health activities. These generally include
the following:
• To report abuse or neglect.
• If you are deemed to be a danger to yourself and/or others
and a decision has been made to implement involuntary commitment
proceedings.
• To notify the appropriate government authority if we believe
a participant has been the victim of abuse or neglect. (We will
only make this disclosure if you agree or when required by law.)
• Health Oversight Activities We may disclose medical information
to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations,
inspections, and accreditations. These activities are necessary
for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
• Lawsuits and Disputes If you are involved in a lawsuit
or a dispute, we may disclose medical information about you in
response to a court, or administrative order, or with an appropriate
release from you.
• Law Enforcement We may release medical information if
asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons,
or similar process.
• About a death we believe may be the result of criminal
conduct.
• About criminal conduct at Breakthrough House.
• In emergency circumstances to report a crime, the location
of the crime or victim, or the identity, description, or location
of the person who committed the crime.
• In situations where a person has been threatened with
substantial physical harm.
• Coroners, Medical Examiners, and Funeral Directors We
may release medical information to a coroner, medical examiner,
or funeral director. This may be necessary, for example, to identify
a deceased person, or determine the cause of death, or carry out
their duties.
• Specialized Government Functions We may release medical
information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized
by law.
• Inmates If you are an inmate of a correctional institution
or under the custody of a law enforcement official, we may release
medical information about you to the correctional institution
or law enforcement official. This release would be necessary:
• For the institution
to provide you with health care;
• To protect your
health and safety or the health and safety of others; or
• For the safety
and security of the correctional institution.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this
notice or the laws that apply to Breakthrough House will be made only
with your written authorization. If you provide Breakthrough House
authorization to use or disclose medical information about you, you
may revoke this authorization verbally or in writing at any time.
If you revoke your authorization, Breakthrough House will no longer
use or disclose medical information about you for the reasons covered
by your written authorization. Of course, we are unable to take back
any disclosures Breakthrough House has already made with your permission
and that we are required to retain our records of care that Breakthrough
House provided to you.
CHANGES TO THIS NOTICE
Breakthrough House reserves the right to change this notice. Breakthrough
House reserves 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. Any changes arising from the
revision process will be incorporated into the privacy notice and
distributed to participants before those practices are effective.
Breakthrough House will post a copy of the current notice at each
site we provide care. The effective date of the notice will be located
on the bottom of the first page.
ACKNOWLEDGEMENT
We are required by law to make a good faith effort to provide you
with our Notice of Privacy Practices and obtain acknowledgement from
you. However, your receipt of care and treatment from Breakthrough
House is not conditioned upon you providing written acknowledgement.
Question: What do I do if
I believe my rights have been violated?
Answer: If you believe your privacy rights
have been violated, you may file a complaint with Breakthrough House
by completing a complaint form or talking to our privacy officer.
You may also file a complaint with the
Secretary of the U.S. Department of Health and Human Services at:
Office of Civil rights,
U.S. Department of Health and Human Services,
601 East 12th Street Room 248,
Kansas City, Missouri 64106,
or by telephone Toll Free
at (877) 696-6775.
You will not be penalized for filing a complaint.
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