Client Confidentiality – Privacy Notice
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. This notice describes the privacy practices of Cenikor Foundation which includes each of our facilities in Texas and Louisiana.
- Our Privacy and Confidentiality Obligations
We are required by law to maintain the privacy and confidentiality of information about your health, health care, and payment for services related to your health (referred to in this notice as “protected health information” or “information”) and to provide you with this notice of our legal duties and privacy practices with respect to your protected health information. When we use or disclose this information, we are required to abide by the terms of this notice (or other notice in effect at the time of the use or disclosure)
- Protected Health Information in connection with alcohol or drug services:
42 CFR Part 2 protects your health information if you are applying for or receiving services (including diagnosis or treatment, or referral) for drug or alcohol abuse. Generally, if you are applying for or receiving services for drug or alcohol abuse, we may not acknowledge to a person outside the program that you attend the program or disclose any information identifying you as an alcohol or drug abuser except under certain circumstances that are listed in this notice.
- All Protected Health Information, including alcohol or drug services:
The Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Regulations (45 CFR Parts 160 and 164), also protect your health information whether or not you are applying for or receiving services for drug or alcohol abuse. Generally, if you are not applying for or receiving services for drug or alcohol abuse, the way we may use and disclose information differs slightly. These differences will be listed in this notice.
- Uses and Disclosures WITH your Authorization. All Protected Health Information
- Generally, we may use or disclose your protected health information when you give your authorization to do in writing on a form that specifically meets the requirements of laws and regulations that apply.
- There are some exceptions and special rules that allow for uses and disclosures without your authorization or consent. They are listed in sections IV and V.
- You may revoke your authorization except to the extent that we have already taken action upon the authorization. If you are currently receiving care and wish to revoke your authorization, you will need to deliver a written statement to your primary counselor or therapist.
- Please be aware of the fact that a court with appropriate jurisdiction or other authorized third party could request or require you to sign an authorization.
- Uses and Disclosures WITHOUT your Authorization: All Protected Health Information
Even when you have not given your written authorization, we may use and disclose information under the circumstances listed below. This list applies to all protected health information, including the information we get when you are applying for or receiving services for drug and alcohol abuse.
- Treatment. We may use or disclose your protected health information for treatment purposes. Treatment includes diagnosis, treatment, and other services, including discharge planning. For example, counselors may disclose your health information to each other to coordinate individual and group counseling sessions for your treatment or information about treatment alternatives or other health-related benefits and services that are necessary or may be of interest to you (45 CFR 164.501, 45 CFR 164.506)
- Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include common activities such as:
- Determining eligibility or coverage under a plan and adjudicating claims;
- Risk adjustments
- Billing and collection activities
- Reviewing health care services for medical necessity, coverage, justification of charges, and the like;
- Utilization review activities; and
- Disclosures to consumer reporting agencies (limited to specified identifying information about the individual, his or her payment history, and identifying information about the covered entity) (45 CFR 164.501, 45 CFR 164.506)
- Health Care Operations. We may use or disclose your protected health information for the purposes of health care operations that include internal administration and planning and various activities that improve the quality and effectiveness of care. For example, we may use your information about your care to evaluate the quality and competence of our clinical staff. We may disclose information to qualified personnel for outcome evaluation, management audits, financial audits, or program evaluation; however, such personnel may not identify, directly or indirectly, any individual patient in any report of such audit or evaluation, or otherwise disclose patient identities in any manner. We may disclose your information as needed with Cenikor in order to resolve any complaints or issues arising regarding your care. We may also disclose your protected health information to an agent or agency which provides services to Cenikor under a qualified service organization agreement and/or business associate agreement, in which they agree to abide by applicable federal law and related regulations (42 CFR Part 2 and HIPAA). Health care Operations may also include use of your protected health information for programs offered by Cenikor, such as sending you invitations to alumni events and workshops sponsored by Cenikor. This list of examples is for illustration only and is not an exclusive list of all the potential uses and disclosures that may be made for health care operations. (45 CFR 164.501, 45 CFR 164.506)
- Other allowable uses and disclosures without your authorization, aside from treatment and health care operations, include:
- Appointment Reminders. We may contact you to send you a reminder notices of future appointments for your treatment. (45 CFR 164.510(b)(3).
- Bed Availability/Waitlist. We may contact you to inform you of bed availability and waitlist status for your treatment. (45 CFR 164.510(b)(3).
- Medical Emergencies. We may disclose your protected health information to medical personnel to the extent necessary to meet a valid medical emergency (42 CFR Part 2, Subpart D)
- Minors. We may disclose to a parent or guardian or other person authorized under state law to act on behalf of a minor, those facts about a minor which are relevant to reducing a threat to the life or physical well-being of the minor or any other individual, if the program assesses that the minor applicant lacks capacity to make a rational decision and the minor’s situation poses a substantial threat to the life or physical well-being of the minor or any other individual which may be reduced by communicating relevant facts to such person. (42 CFR 2.14)
- Incompetent and Deceased Clients. In such cases, authorization of a personal representative, guardian, or other person authorized by applicable state law may be given in accordance with 42 CFR Part 2. (42 CFR 2.15)
- Decedents. We may disclose protected health information to a coroner, medical examiner or other authorized persons under laws required the collection of death or other vital statistics, or which permit inquiry into the cause of death. (42 CFR 2.15)
- Judicial Proceedings and Law Enforcement. We may disclose your protected health information in response to law enforcement or a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records. Note also that if your records are not actually “client records” within meaning of 42 CFR Part 2 (e.g., if your records are created as a result of your participation in the family program or another non-treatment setting), your records may not be subject to the protections of 42 CFR Part 2. We may disclose your protected health information to the police or other law enforcement officials if you commit a crime on the premises or against program personnel or threaten to commit such a crime. (42 CFR Part 2, subpart E)
- Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. (45 CFR 164.512(b)(1)(ii), (45 CFR 164.512(c))
- Public Health/Health Oversight. We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted, by law, to collect or receive the information. We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights law (45 CFR 164.512(d))
- Food and Drug Administration. We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to tract products; to enable product recalls; to make repairs or replacements or to conduct post marketing surveillance, as required. (45 CFR 164.512(b))
- Research. We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. (45 CFR 164.501)
- Military Activity and National Security. When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorizes; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. (45 CFR 164.512(k))
- Workers’ Compensation. We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs. (45 CFR 164.512(l))
- Incarcerated Individuals. We may use or disclose your protected health information if you are incarcerated at a correctional facility and your physician created or received your protected health information in the course of providing care to you. (42 CFR 164.501)
- Audit and Evaluation Activities. We may disclose protected health information to those who perform audit or evaluation activities for certain health oversight agencies, e.g. state licensure or certification agencies and the Commission on the Accreditation of Rehabilitation Facilities (CARF). (45 CFR 164.501)
- Fundraising Communications. In connection with any grants and fundraising opportunities, we may use certain demographic information about you and dates of health care provided to you. (45 CFR 164.501)
- Your Rights
- Right to Receive Confidential Communications. Normally we will communicate with you through the phone number and/or address you provide. You may request, and we will accommodate, any reasonable, written request for you to receive your protected health information by alternative means of communication or at alternative locations. (45 CFR 164.522(b))
- Right to Request Restrictions. At your request, we will not disclose health information to your health plan if the disclosure is for payment of a health care item or service for which you have paid Cenikor out of pocket in full. You may request additional restriction on our use and disclosure of protected health information for treatment, payment and health care operations. While we will consider requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions and you are currently receiving services, please contact your counselor. If you are no longer receiving services, please contact Cenikor Corporate Office. (45 CFR 164.522(a))
- Right to Inspect and Copy Your Health Information. You may request access to your clinical file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records and you are currently receiving services, please ask your counselor. Once you are no longer receiving services, contact Cenikor Corporate Office in writing. (42 CFR 2.23)
- Right to Amend Your Records. You have the right to request that we amend protected health information maintained in your clinical file or billing records. If you desire to amend your records and you are currently receiving services, please contact your counselor. Once you are no longer receiving services, contact Cenikor Corporate Office in writing. Under certain circumstances, Cenikor has the right to deny your request to amend your records and will notify you of this denial as provided in the HIPAA regulations. If your requested amendment to your records is accepted, a copy of your amendment will become a permanent part of the medical record. When we “amend” a record, we may append information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement or disagreement placed in your medical records. (45 CFR 164.526 (b)(2))
- Right to Receive an Accounting of Disclosures. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure to family members or friends involved in your care, or for notification purposes, for nation security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. (45 CFR 164.528(a))
- Right to Receive Notification of Breach. You will be notified immediately in the event we discover a breach has occurred such that your protected health information may have been compromised. Notification will be made no more than 60 days after the discovery of the breach, unless it is determined by a law enforcement agency that the notification should be delayed. (45 CFR 164.400-414)
- Additional Information
- Right to Receive a Paper Copy of This Notice. Upon request, you may obtain a paper copy of this notice.
- For Further Information and Complaints. If you desire further information about your privacy and confidentiality rights, you may contact Cenikor Corporate office at 713-266-9944. You may call this number if you are concerned that we have violated your privacy rights, if you disagree with a decision that we made about access to your protected health information, or if you wish to complain about our breach notification process. You may also file a written complaint with the Secretary of the United States Department of Health and Human Services. Upon request, we will provide you with the correct address. We will not retaliate against you if you file a complaint. Violation of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney in the district where the violation occurs.
- Effective Date and Duration of This Notice
- Effective Date. This notice is effective on August 31, 2015.
- Right to Change Terms of This Notice. We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective to all protected health information that we maintain, including any information created or received prior to issuing the new notice. If we change this notice, we will post the new notice in public access areas at our service sites and on our Internet site at cenikor.org. You may also obtain a new notice by contacting Cenikor Corporate Office.
- Privacy Office. You may contact Cenikor Corporate Office at 713-266-9944