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Mental Health Association in Orange county Inc.
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
This notice describes how personal information about you may be used and disclosed and how you can get access to this information.
Please review it carefully. *Privacy Promise
Mental Health Association in Orange County, Inc. (MHA) understands that your personal information needs to be kept private. Protecting your personal information is important. We follow strict federal and state laws that require us to keep your personal information confidential.
*How We Use Your Personal Information
When you receive services from MHA, we may use your personal information for such activities as providing you with services, billing for services, and conducting our normal business known as health care operations. If you have chosen a personal representative and have agreed to let your personal representative obtain your personal information, we will provide the information to your personal representative. If you have a guardian we will provide the information to your guardian. Examples of how we use your information include:
· Treatment - We keep records of the care and services provided to you within MHA. For example, your case manager keeps notes on all contacts made in coordinating and arranging for services. If you receive Residential Habilitation Services, the Res Hab worker will keep records of any care you receive. MHA staff may share your personal information while helping to develop your service plan. If MHA staff want to share your personal information with anyone who is not employed by MHA, you must give them written permission first. Some personal records, including confidential communications with a mental health professional, substance abuse records, and HIV/AIDS information may have additional restrictions for use and disclosure under state and federal law. · Payment – We keep records that include payment information and documentation of the services provided to you. Your information may be used to obtain payment for your services from Medicaid, or other sources. For example, we may disclose personal information about the services provided to you to confirm your eligibility for Medicaid and to obtain payment from Medicaid. MHA may use your personal information to determine the amount and type of Medicaid services you need and send this information to the proper state department · Health Care Operations – We use personal information to improve the quality of care, train staff, manage costs, conduct required business duties, and make plans to better serve you and other individuals who receive services from MHA. For example, we may use your personal information to evaluate the quality of treatment and services provided by our service staff. · Fundraising – We may use demographic information about you in order to support our business operations. · Business Associates – We may disclose your personal health information with an accounting firm or law firm that provides professional advice to us about how to improve on health care services and comply with the law.
*Other Services We Provide
We may also use your personal information to: · Determine whether you are eligible for services from MHA. · Recommend to you service alternatives and other possible benefits. · Tell you about other service providers who may be able to help you. · Remind you of an appointment unless you tell MHA staff that you do not wish to be reminded. · To allow MHA to review direct service contracts. · Allow local, state, federal agencies to monitor your services. · To investigate incidents affecting health and safety, to report these kind of incidents and to take steps to protect your health and safety. · To allow MHA to prepare reports required by the New York State Office of Mental Retardation and Developmental Disabilities, the New York State Office of Mental Health, and other funding sources.
*Sharing Your Personal Information
There are limited situations when we are permitted or required to disclose personal information without your signed authorization. These situations are: · To protect victims of abuse, neglect, or domestic violence. · To reduce or prevent a serious threat to public health and safety. · For health oversight activities such as investigations, audits, and inspections. · For lawsuits and similar proceedings . · For public health purposes such as reporting communicable diseases, work-related illnesses, or other diseases and injuries permitted by law; reporting births and deaths, and reporting reactions to drugs and problems with medical devices. · When required by law. · When requested by law enforcement as required by law or court order. · To coroners, medical examiners, and funeral directors. · For organ and tissue donation. · For workers’ compensation or other similar programs if you are injured at work and are covered by workers’ compensation or other similar programs. · For specialized government functions such as intelligence and national security. · For product monitoring and recall. · For research, with your consent., or when a review board has approved research which poses minimal risk and your privacy is ensured. No public disclosure of your name will be made without your consent. All other uses and disclosures, not described in this notice, require your signed authorization. You may revoke your authorization at any time with a written statement.
*WHO WILL FOLLOW THIS NOTICE
· All MHA employees, consultants, interns, volunteers, and business associates.
*Our Privacy Responsibilities
MHA is required by law to: · Maintain the privacy of your personal information. · Provide this notice that describes the ways we may use and share your personal information. · Follow the terms of the notice currently in effect. We reserve the right to make changes to this notice at any time and make the new privacy practices effective for all information we maintain. Current notices will be posted in all MHA facilities. You may also request a copy of any notice from the MHA Privacy Office. *Your Individual Rights
You have the right to: • Request restrictions on how we use and share your personal information. We will consider all request for restrictions carefully but are not required to agree to any restriction.* • Request that we use a specific telephone number or address to communicate with you. • Inspect and copy your personal information, including service, medical and billing records. Fees may apply.* • Request corrections or additions to your personal information . You must give the reasons for wanting the change.* • Request an accounting of certain disclosures of your personal information made by us. Your request must state the period of time desired for the accounting, which must be within the six years prior to your request. The first accounting is free but a fee will apply if more than one request is made in a 12-month period.* • Request a paper copy of this notice even if you agree to receive it electronically. Requests marked with a star (*) must be made in writing. Contact MHA Privacy Office for the appropriate form for your request. *Our Organization
This notice describes the privacy practices of the Mental Health Association in Orange County (MHA). This notice also describes the privacy practices of persons or entities which have signed a contract with MHA and which are acting as business associates, and have promised to follow the same rules of confidentiality.
MHA Facilities include: · MHA office in Goshen, NY · Hudson House in Newburgh, NY · Home-to-Stay in Middletown, NY
If you want to know about the privacy practices of service providers who are not employed by the MHA and who are not business associates, you should contact them directly. Contact Us
If you would like further information about your privacy rights, are concerned that your privacy rights have been violated, or disagree with a decision that we made about access to your personal information, please contact MHA’s Privacy Office: Privacy Contact
20 Walker Street
Goshen, NY, 10924
Tel: (845) 294-7411 ext. 243 Fax: (845) 294-7348
*HOW TO FILE A COMPLAINT
· To file a complaint with us, please contact Privacy Contact at Mental Health Association in Orange County, Inc., 20 Walker Street, Goshen, NY 10924, (845) 294-7411 ext. 243. We will investigate all complaints and will not retaliate against you for filing a complaint.
You also may file a written complaint with either · The Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775 or · The Office for Civil Rights, U.S. Department of Health and Human Services at 200 Independence Avenue SW, Room 509F, HHH Building, Washington D.C., 20201 or call OCR’s hotline – voice at 1-800-368-1019, or e-mail at ocrmail@hhs.gov. · In addition, the Federal Center for Deaf and Hearing Impaired can be contacted at 1-800-877-8339. MENTAL HEALTH ASSOCIATION IN ORANGE COUNTY, INC.
20 WALKER STREET
GOSHEN, NY 10924
(845) 294-7411
FAX: (845) 294-7348
I have received a copy of the privacy practices notice from the Mental Health Association in Orange County, Inc. I also consent to the disclosure of personally identifiable information for treatment, payment and normal healthcare business operations of this agency in regard to myself and others noted below for whom I can legally consent.
Printed Name of Client
Printed Name of Others Subject to this Consent (For example, minors)
Signature – describe legal relationship to others
Date
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(c) 2007 Mental Health Association, in Orange County. All rights reserved. |
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