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Douglas County Mental Health Department
Douglas County Mental Health Notice of Privacy Practices, Effective September 16, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION WILL BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO IT. PLEASE READ IT CAREFULLY.
This notice is to comply with the federal law “Health Insurance Portability and Accountability Act of 1996”. Protecting the privacy of information about your medical conditions and health is a responsibility we take very seriously. We understand that medical information about you and your health is personal and it is important to you that we keep it confidential. We are committed to the practices and procedures we have established to protect the confidential nature of information about your health. Douglas County Mental Health, hereafter referred to as DCMH, is required by law to protect the privacy of your personal health information and provide you with this notice that explains our legal duties and our privacy information practices. Each time you visit a healthcare provider a record is created to capture the care, treatment or services provided. This information is kept and put together in order to follow certain laws, rules and to keep track of business practices. This notice will describe some of the ways we may use or share your personal health information, your rights, and our obligations to protect and safeguard this information. Health information includes and relates to:
Your past, present, and future medical or mental health conditions
Your past, present, or future payment for the care or services you received
Care and services provided to you
How your PHI will be Used The following categories describe the different ways your personal health information may be disclosed by DCMH. In order to provide effective care, it is sometimes necessary to share your information.
TREATMENT We may use personal health about you to provide you will appropriate and effective treatment or services. We may disclose personal health information to psychiatrist, nurses, interns, or other agency personnel who are involved in your treatment or care. We will share information with others outside DCMH only with your written authorization to do so.
PAYMENT We may use and disclose your personal health information about you so that the treatment and services you receive from DCMH may be billed and payment collected from you, an insurance company, or a third party.
HEALTHCARE OPERATIONS We may use and disclose personal health information for DCMH business operations. These disclosures are necessary to maintain agency efficiency and ensure you are receiving quality care. This may include reviewing your plan of care in staff trainings. Revisions / Changes to Privacy Notice DCMH reserves the right to revise or change the contents of this notice. Should we change the contents; a new notice will be available within 30 days from the effective date of the change. This new notice will apply to all personal health information maintained by DCMH, regardless of where the information was gathered. The new notice will state “Revised” and will include the date the change becomes effective. Each time you come to DCMH for services you will be offered a copy of the current notice. DCMH Responsibilities under the Federal Privacy Standard All employees, volunteers, and contractors must protect the privacy of your information. Employees, volunteers, and contractors may only access/use your information if it directly relates to the job or services they provide. DCMH will penalize employees, volunteers, and contractors who do not protect your information. Uses and Disclosures DCMH will not use or disclose your personal health information for any other purposes unless you give DCMH your written authorization to do so. For example, DCMH would need your prior, written authorization to use or disclose your personal health information for marketing purposes, for most uses or disclosures of psychotherapy notes (where appropriate), or if we intended to sell your personal health information. Other uses and disclosures not described in this document will be made only with written authorization. In most cases, you may revoke your written authorization at any time. Your revocation will be effective from the date we are notified of your request. Authorization and Revocation Forms are available from the receptionist. DCMH may use or disclose other health information that is not covered by this notice or by the federal and state laws only with your written authorization.
HIV/AIDS Status The AIDS Confidentiality Act (410 ILCS 305) and the AIDS Confidentiality and Testing Code (77 IL Adm Code 697)(AIDS Code) protects the identity of a person upon whom a test for HIV is performed and the results of a test for HIV on an individual. An HIV antibody or AIDS test cannot be required as a condition of treatment, and an individual cannot be required to disclose or sign an authorization for release of information concerning his/her HIV antibody test or HIV/AIDS status as a condition of treatment. See separate agency confidentiality policy entitled “Confidentiality Regarding HIV/AIDS”. Purposes for which DCMH may Disclose your Personal Health Information without Authorization AS REQUIRED BY LAW 1. DCMH may disclose information necessary to comply with a court order and subpoena for your records. A subpoena alone would not permit us to disclose any information. (Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110). 2. DCMH may also be required to disclose personal health information to comply with abuse and/or neglect laws to governmental or social service agencies, including court proceedings. These include laws under the Illinois Abused and Neglected Child Reporting Act (325 ILCS 5/1) and Elder Abuse and Neglect Act (320 ILCS 20/1 et seq). 3. DCMH may also be required to disclose personal health information if it is determined that the probability of immediate, physical harm to you or others mat occur and information is needed to prevent it. We may notify persons who are directly being threatened as outlined in the duty to warn law as well as law enforcement personnel. (Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110). 4. In accordance with the Sexually Violent Persons Commitment Act (725 ILCS 207/1). 5. To initiate or continue commitment proceedings or to otherwise protect you or another person against clear, imminent risk of serious physical or mental injury, disease, or death being inflected upon you or by you on another. (Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110). 6. Records and communications may be disclosed in a proceeding under the Probate Act of 1975 to determine a recipient’s competency or need for guardianship, provided that the disclosure is made only with respect to that issue. (740 ILCS 110/10(5)). 7. To the Secretary of the U.S. Department of Health and Human Services in order to determine if DCMH is compliant with privacy laws and to investigate complaints received regarding privacy violations. (45 CFR §160.308). 8. To the Office of Inspector General to investigate complaints of abuse and neglect to consumers of DCMH. (740 ILCS 110/10bf; 405 ILCS 45/Protection and Advocacy for Mentally Ill Persons Act; Abuse of Adults with Disabilities Intervention Act). 9. Information may be provided as mandated by law to provide public health information of a communicable disease.
COMMUNICATION WITHIN THE AGENCY Information may be disclosed for communications within DCMH between staff who have a need for the information in connection with their job duties that stem from a diagnosis, treatment or referral for treatment; supervision; and consultation. This also includes information shared for other functions such as billing.
HEALTH SERVICES DCMH may disclose your information to our business associates so that they can perform services for which they were contracted. We require our business associates to properly safeguard your information. Examples include when sharing information is necessary to collect sums or receive third party payment for mental health services received from this agency. This may also include accreditation, audit and evaluation activities; however it is DCMH’s policy to obtain your authorization prior to your personal health information being reviewed for these purposes. Disclosure is limited to information needed to pursue collection.
APPLY FOR AND RECEIVE BENEFITS Information from a consumer’s record that is necessary to enable him/her to apply for or receive benefits may be disclosed without consent when despite every reasonable effort, it is not possible to obtain consent. This may be because the person entitled is not capable of consenting or is not available to do so. The information disclosed may only include the identity of the consumer, therapist, and a description of the nature, purpose, quantity and date of services provided. The consumer will be informed of disclosure made without consent. (740 ILCS 110/6).
MEDICAL EMERGENCY Restricted health information, may be disclosed to another health care provider to provide emergency treatment when immediate medical intervention is necessary. We will request that the other provider does not make further use/disclosures of your information.
COURT ORDERED EXAMINATIONS DCMH may disclose your information if a court orders you to be examined for conditions related to mental health or other disorders. This occurs only if the court has documented you have consented to this disclosure and are aware information about you condition, evaluation and services will not be kept confidential.
COUNSEL OR LEGAL ADVOCATE DCMH or an individual therapist may consult with an attorney or legal advocate about their legal rights or duties in relation to you and the services provided.
CONTINUITY OF CARE For the purposes of continuing care, the Department of Human Services, community agencies funded by the Department of Human Services, prisons operated by the Department of Corrections, mental health facilities operated by a county, and jails operated by any county of Illinois may disclose your record or communications, without consent, to each other, but only for the purpose of admission, treatment, planning or discharge to another setting.
MENTAL HEALTH AND DEVELOPMENTAL DISABLITIES REVIEW BOARD The Medical Review Board shall be entitled to inspect and copy the records of any recipient. Information obtained may not be redisclosed without written authorization. CENSUS BUREAU Information necessary to complete the requirements of the Census Bureau may be provided without consent. Rights Regarding Your Personal Health Information
ACCESS AND COPY You or your authorized representative has the right to inspect and/or receive a copy of your health information (in most situations) to include medical and billing records. Authorized representatives may include: 1. The parent or guardian if the recipient is under age 12 2. The guardian of a recipient who is age 18 and over 3. An attorney or guardian ad litem representing a minor 12 years or older with a court order. 4. An agent appointed as Power of Attorney for Health Care or Property 5. An attorney-in-fact named in a declaration of preferences or instructions regarding mental health treatment under the Mental Health Treatment Preference Declaration Act (755 ILCS 43/). 6. A parent or legal guardian of a recipient of services who is over 12 but under 18 may have access to records about the child’s current condition, diagnosis, treatment and medications provided and treatment and services needed. The parent or guardian may have access to other kinds of mental health records if the child does not object or if the therapist does not feel there are strong reasons to deny the parent or guardian access to records. If the therapist or child denies access to those records, the parent or guardian may file a court action to seek access. Under state and federal laws, health information does not include personal psychotherapy notes or information compiled about your health in reasonable anticipation of litigation, administrative action or administrative proceedings. You can obtain a form to request access to your information from the receptionist. The form must be filled out and signed and state a specific time period for the records you want to view or have access to. If you request for access is approved, you will be contacted to schedule a convenient appointment. DCMH may charge a fee for processing your request. We will respond to your request within 30 days.
AMMENDMENT AND MODIFICATION OF INFORMATION You have the right to ask DCMH to amend or change the information in your chart if you feel it is incorrect or incomplete. You may obtain a form to document your request/amendment from the receptionist. In order for your request to be approved:
Your request must be in writing
It must include a reason why you want to add or change your record
It must state a specific time or episode of care
If we accept the request (in whole or in part), we will notify you that the amendment has been accepted within 30 days and ask you to identify others who should receive it. DCMH will then make reasonable efforts to inform and provide the amendment to identified individuals. The amended information is added to the chart and maintained by for six years after services are discontinued. If your request is denied, you have a right to submit a written statement to disagree with the “Denial of Amendment.” You may obtain a form from the receptionist to write your “Statement of Disagreement” which will be forwarded to the Privacy Officer. We will include both the copy of the “Denial of Amendment” and the “Statement of Disagreement” with any future disclosures. In addition, we may choose to write a written response to your statement.
REQUEST RESTRICTIONS/LIMITATIONS ON USE OR DISCLOSURE You have the right to request a restriction or limitation on your personal health information that we use or share for treatment, payment and health care operations. You also have a right to limit the information we share to providers or payees. We will consider your request; however we are not required to agree to a restriction. DCMH is required to agree to a request to restrict disclosure of personal health information to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or services for which the consumer has paid out of pocket, in full. We cannot agree to restrict disclosures that are required by law. Termination of Agreement of Restriction/Limitation DCMH may terminate the agreement to a restriction if you agree to or request an end to the restriction in writing. DCMH may also end the agreement without your permission as long as you are informed of the termination. This will only effect your personal health information that was created or received after you have been informed of the termination.
ACCOUNTING OF DISCLOSURES You have a right to request an accounting of disclosures of your personal health information. This is a list of each time we have shared health information about you. You may request an accounting for a period shorter than six years or for a specified date within the six-year period and may only be for disclosures that occurred after October 31, 2006. Your request must be in writing and we may charge you a reasonable fee.
REQUEST ALTERNATIVE COMMUNICATION You have the right that we communicate to you in confidence about you health information through another means or to an alternate location when this can be reasonably carried out. You may obtain a form to document your request from the receptionist. We will not require an explanation for why this is needed and we will make every attempt to satisfy reasonable requests. Examples of alternate communication include but are not limited to: contacting you only at work, mailing information to another address or speaking to you in your own language through the use of a translator.
RECEIVE A PAPER COPY AND ADDITIONAL INFORMATION You have the right to obtain a paper copy of this notice at any time. To request additional copies of this notice or additional information, contact the Privacy Officer at DCMH.
RECEIVE A PRIVACY BREACH NOTICE You have the right to receive written notification if DCMH discovers a breach of your unsecured protected health information, and determines through risk assessment that notification is required.
COMPLAINT PROCESS If you believe any of your privacy rights have been violated by DCMH, you have the right to file a complaint with our privacy officer. A formal complaint form can be obtained from the receptionist. You may also file a complaint directly with the Secretary of the U.S. Department of Health and Human Services.
Jan Aten, Privacy Officer at DCMH Privacy Officer of U.S. Dept. of Health and Human Services 114 W. Houghton St 233 N. Michigan Ave, Suite 240 Tuscola, IL 61953 Chicago, IL 60601 Phone/TTY: 217-253-4731 Phone: 312-886-2359 Fax: 217-253-4733 TDD: 312-353-5693 Email: email@example.com Fax: 312-866-18