Coastal Horizons Center, Inc.
This Notice is effective on April 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Information regarding your health care, including payment for health care, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 U.S.C. § 1320d et seq, 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Under these laws, Coastal Horizons Center, Inc. (Coastal Horizons Center) may not say to a person outside of Coastal Horizons Center that you attend(ed) or receive(ed) services, nor may Coastal Horizons Center disclose any information identifying you as an alcohol or drug abuser, or disclose any other protected information except as permitted by federal law.
Coastal Horizons Center must obtain your written authorization before it can disclose information about you for payment purposes. For example, Coastal Horizons Center must obtain your written authorization before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written authorization before Coastal Horizons Center can share information for treatment purposes or for health care operations. However, federal law permits Coastal Horizons Center to disclose minimum necessary information without your written permission:
- For research, audit or evaluations,
- To report a crime committed on Coastal Horizons Center’s premises or against Coastal Horizons Center personnel;
- To medical personnel in a medical emergency,
- To appropriate authorities to report suspected child abuse or neglect;
- As allowed by a court order.
- Among our workforce, on a need to know basis, to coordinate your care,
- Among our workforce or within an entity having direct administrative control, on a need to know basis, to conduct our health care operations,
- To individuals or entities that help Coastal Horizons Center conduct duties in serving you with whom we have a Qualified Service Organization (QSO) or Business Associate (BA) agreement.
For example, Coastal Horizons Center can disclose information without your authorization to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a business associate agreement in place.
Before Coastal Horizons Center can use or disclose any information about your health care, in a manner that is not described above, Coastal Horizons Center must first obtain your specific written authorization allowing it to make the disclosure. You may revoke any written authorization. The revocation must be in writing.
This section will briefly mention your privacy rights. If you would like to know more about these rights, please contact the Privacy Officer at 343-0145.
Right to a Copy of Notice: You have a right to receive a paper copy of our Notice at any time. In addition, a copy of this Notice will always be posted in our waiting area and on the Coastal Horizons Center website: http://www.coastalhorizons.org. You may download a PDF version of this notice here.
Right to inspect and request copy of record: In most cases, you have the right to look at or get copies of your records. You must make the request by writing a letter to the Privacy Officer or completing an Access Request Form. You may obtain an Access Request Form from the receptionist. You may submit the completed Access Request Form to your service provider or the receptionist. Coastal Horizons Center will respond to your request within 30 days. In some cases, Coastal Horizons Center may deny your request. If your access is denied, Coastal Horizons Center will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your record, a charge for copying may be imposed depending upon your circumstances. You have a right to choose what portions of your information you want copied and to have prior information regarding the cost of copying.
Right to Request Amendment to Record: If you believe that your health information is wrong or some information is missing in your record, you must request, in writing, that Coastal Horizons Center correct or add to the record by writing a letter to the Privacy Officer or completing an Amendment Request Form. You may obtain an Amendment Request Form from the receptionist and you may submit the completed Amendment Request Form to your service provider or the receptionist. Coastal Horizons Center will respond within 60 days of receiving your request. Coastal Horizons Center may deny the request if it is determined that the information is:
- correct and complete, or
- not created by Coastal Horizons Center and/or not part of agency records, or
- not permitted to be disclosed, i.e., information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in
other limited circumstances.
Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement that you provide in response, added to your health information. If Coastal Horizons Center approves the request for amendment, we will change the information in your record, inform you, and tell others who need to know about the change.
Right to Request an Accounting of Certain Disclosures: You have the right to request an accounting (a detailed listing) of disclosures that Coastal Horizons Center has made for the previous 6 years (beginning April 14, 2003). If you would like to receive an accounting, you may send a letter to the Privacy Officer or complete an Accounting Request Form. You may obtain an Accounting Request Form from the receptionist. You may submit the completed Accounting Request Form to your service provider or the receptionist. Coastal Horizons Center must act on this request no later than 60 days after receipt of the request. The accounting will not include several types of disclosures including disclosures for treatment, payment or health care operations. It will also not include disclosures before April 14, 2003. If you request an accounting more than once every 12 months, we may charge you a fee to cover the costs of preparing the accounting.
Request a Restriction of Uses or Disclosures: You have the right to ask that Coastal Horizons Center limit how your health care information is used or disclosed. You may make requests in writing by completing a Restriction Request Form. You may obtain a Restriction Request Form from the receptionist and submit the completed form to the receptionist or your service provider. Coastal Horizons Center will consider your request, but is not legally bound to agree to the restriction. To the extent that we do agree to any restriction on our use/disclosure of your information, we will put the agreement in writing and abide by it except, as necessary, in medical emergencies. We cannot agree to limit uses/disclosures that are required by law. You must submit a request in writing to cancel the restrictions. Coastal Horizons Center may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.
Right to Request an Alternate Method of Contact: You have the right to ask that we send your health care or billing information to or contact you at an address or phone number than is different than your home. We must agree to your request as long as it is reasonably easy for us to do so. You must make this request in writing by completing an Alternate Contact Request Form. You may obtain these forms from the receptionist and submit the completed form to the receptionist or your service provider. You do not have to explain the reason for your request. Please be aware that if you are using a cellular telephone or mobile phone, other cellular/mobile telephone users may intercept your conversations.
How to File a Complaint or Report a Violation: If you believe your privacy rights have been violated or you are dissatisfied with the Coastal Horizons Center privacy policies, procedures or practice, you can file a complaint or grievance in person or in writing with/to any appropriate staff member or the Privacy Officer. You may obtain a complaint form from the receptionist or the Privacy Officer. Individuals may file a written complaint with the US Department of Health and Human Services (DHHS) Office for Civil Rights (OCR) by mail, fax or e-mail at the address listed below: [Region IV]
Office for Civil Rights
U.S. Dept. of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, SW
Atlanta, GA 30303-8909
Voice Phone: (404) 562-7886
FAX: (404) 562-7881
TTD: (404) 331-2867
For all complaints filed by e-mail send to: OCRComplaints@hhs.gov
Individuals may, but are not required to, use OCR’s Health Information Privacy Complaint Form. To obtain a copy of this form, or for more information about the Privacy Rule or how to file a complaint with OCR, contact any OCR office or go to www.hhs.gov/ocr/hipaa/.
Complaints must be filed with US DHHS within 180 days of when you knew or should have known that the act had occurred. The Secretary may waive this 180-day time limit if good cause is shown. There will be no retaliation against you for filing a complaint.
Violation of the Confidentiality Law is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.
Duties of Coastal Horizons Center
Coastal Horizons Center is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. This may be information about health care services that we provide to you or payment for health care provided to you. It may also be information about your past, present or future health care condition.
Coastal Horizons Center is required by law to provide you with this Privacy Notice explaining our legal duties and privacy practices with respect to health care information. We are also required by law to abide by the terms of this Notice.
Coastal Horizons Center may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all health care information that we maintain. If we make changes to the Notice, we will:
• Post the new Notice in our waiting area,
• Have copies of the new Notice available upon request,
• Post the new Notice on the agency website at: http://www.coastalhorizons.org
For More Information: If you have questions or would like additional information, you may speak to your service provider or the Privacy Officer at 343-0145.