ÄDELBROOK’S NOTICE OF PRIVACY PRACTICES
Your Rights and Choices Concerning Your Information and Our Responsibilities:
You have the right to:
- Get a copy of your paper and/or electronic medical/clinical record.
- Correct any errors in your paper and/or electronic record.
- Request confidential communication.
- Ask us to limit the information we share.
- Get a list of those with whom we have shared your information.
- Get a copy of this privacy notice.
- Choose someone to act for you.
- File a complaint if you believe your privacy rights have been violated.
You have some choices in the way we use and share information, as we:
- Tell family and friends about your condition.
- Provide disaster relief.
- Provide mental health care.
- Market our services.
- Fund raise.
Our Uses and Disclosures:
We may use and share your information as we:
- Treat you.
- Run our organization.
- Bill for your services.
- Help with public health and safety concerns.
- Comply with the law.
- Address Workers Compensation, law enforcement and other governmental requests.
- Respond to legal actions and suits.
When it comes to your protected health information, you have certain rights. This section will explain those rights and our responsibilities.
- You may get a copy of your paper and/or electronic medical/clinical record.
- You can ask to see or get a copy of your electronic and/or paper medical/clinical record. We will ask you to put the request in writing.
- We will provide you with a copy or a summary of your health information, usually within thirty days of your request.
- We may charge you a reasonable copying fee.
- You may ask us to correct any errors in your paper and/or electronic record.
- If you see an error or an omission in your record, you can ask us to make corrections in your record.
- We may deny your request but we will tell you why in writing within 60 days.
- You may request confidential communication.
- You can ask us to contact you in a specific way, for example on your home or office phone, or by mail, or by text messaging or email, when allowable by law and agency policy.
- We will agree to all reasonable requests.
- You may ask us to limit the information we share.
- If you pay for a service “out of pocket”, you can ask us not to share that information with your insurance carrier. We will comply unless we are required by law to share the information.
- You may get a list of those with whom we have shared your information.
- You may ask for a list of all the times we have shared your health information for up to the prior six years from the date of your request.
- You may know who, and why we have shared the information.
- We will include all disclosures except for those about treatment, payment and health care operations as required by us under federal and state law.
- You may get a copy of this privacy notice.
- You may get a copy of this notice at any time.
- You may also find it on our website; adelbrook.org
- You have the right to choose someone to act for you
- If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure that person has the legal authority and can act for you before we take any action.
- You have the right to file a complaint if you believe your privacy rights have been violated.
- If you believe your rights have been violated, you may file a complaint with the Chief Compliance Officer, or any other Officer of the agency.
- You can also file a complaint with the Department of Health and Human Services by mailing your complaint to: Centralized Case Management Operations
S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201 or Email: OCRComplaint@hhs.gov
- You may NOT be retaliated against for filing a complaint.
Unless we are required by state or federal laws, you may choose to limit what we share and with whom.
- You have choice in the way we share information to your family and friends.
- You may limit what and how much information you want us to share with your family and friends unless withholding the information may be detrimental to your care.
- You may limit what information we may share with disaster relief organizations.
- If you are unable to tell us your choices in a disaster relief situation due to injury, etc., we may go ahead and share information we believe is necessary in your best interest.
- You may choose to limit what information is shared about you in the provision of mental health care.
- You will not be forced to disclose or reveal personal information you are not willing to share with others.
- You may choose to allow us to use information about you for the purpose of market our services.
- You may choose to decline to allow us to use information about you in marketing our services, your treatment and access to services will not be impacted by your choice.
- You may choose to allow us to use information about you for fund raising.
- You may choose to decline to allow us to use information about you in fund raising; your treatment and access to services will not be impacted by your choice.
Our Uses and Disclosures:
We typically will use or share your information in the following ways;
- We may share your information with other health care professionals who are giving you treatment services such as medical, dental, emergency care, etc.
- We may share your information in the course of running our organization. This may involve financial audits, administrative reviews, accreditation operations, licensing inspections, local and state inspections, quality improvement operations and other business operations.
- We may share your information to bill for your services.
- We may share your information to comply with public health and safety concerns.
- We may share your information to comply with the state and federal laws.
- We may share your information when addressing Workers Compensation, law enforcement and other governmental requests.
- We may share your information in response to a court or administrative order, or in response to a subpoena or bench warrant.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We will not share your personal information other then as described above and as permitted by law without your consent in writing. You may revoke a written release of information at any time and you must inform us of the revocation.
We will provide you with a copy of this notice upon your request.
We will not share any substance abuse treatment records or mental health treatment records without your written permission.
Change to the Terms of the Notice:
We reserve the right to change the terms of this notice, changes may be effective for all past and future information we have about you.
We will provide you a copy of the revised Notice upon request.
Effective date: November 1, 2019
For any concerns regarding the privacy or security of your information, please contact our Chief Compliance Officer:
Patricia Clark at email@example.com or by calling (860) 635-0330 x 218.