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.

Columbia Community Mental Health Privacy Requirements

We are required by law to maintain the privacy of medical and health information about you (“Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health 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).

Uses and Disclosures with Your Consent

Except in an emergency or other special circumstances (as a condition of treatment before providing treatment to you), we will ask you to read and sign a written consent to our use and disclosure of Protected Health Information for purposes of treatment provided to you, obtaining payment for services provided to you and for our health care operations (e.g., internal administration, quality improvement and customer service) as detailed below:

Treatment

We use and disclose Protected Health Information to provide treatment and other services to you (e.g., to diagnose and treat your illness or to help you resolve the issues that brought you to treatment). In addition, we may contact you to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.

Payment

We may use and disclose Protected Health Information to obtain payment for services that we provide to you (e.g., disclosures to claim and obtain payment from the Oregon Medicaid program or your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care to verify that your payer will pay for the services we provide to you.

Health Care Operations

We may use and disclose Protected Health Information for our health care operations, which include internal administration, planning, and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our staff.

Uses and Disclosures of Highly Confidential Information with Your Authorization

As discussed, Federal and Oregon laws impose additional limitations on our use and disclosure of highly confidential information even though you have already signed your consent. In order for us to use or disclose highly confidential information for a purpose other than a purpose permitted under these laws, we must obtain your written authorization. We use and disclose highly confidential information only with your knowledge and limited by a particular purpose.

Highly confidential information includes psychotherapy notes and Protected Health Information about

  • Alcohol and Drug Abuse Prevention, treatment and Referral
  • HIV/AIDS Testing
  • Genetic Information

As described above, your consent only permits us to use Protected Health Information for purposes of treatment, payment and our health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment and health care operations only when:

  • You Give Us Your Authorization On Our Authorization Form
  • Or As Indicated Below:

Uses and Disclosures Without Your Consent or Your Authorization

We may use or disclose Protected Health Information for purposes of treatment, obtaining payment and our health care operations without your consent or authorization under the following three circumstances

  • When you require emergency treatment;
  • When we are required by law to treat you and we attempt to obtain your consent, but are unable to obtain it; and
  • When we attempt to obtain your consent but are unable to obtain it due to substantial barriers to communicating with you (e.g., you are unconscious or otherwise incapacitated), and you would have consented in the absence of the barriers.

We may disclose Protected Health Information for the following public health activities and purposes:

  • To report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability;
  • To report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports;
  • To report information about products under the jurisdiction of the U.S. Food and Drug Administration;
  • To alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and
  • To report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

We may disclose Protected Health Information without Your Consent or Your Authorization if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and/or ensures compliance with the rules of government health programs such as Medicare or Medicaid.

We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process. Unless authorized by a court order, however, we may not use or disclose Protected Health Information identifying you as a recipient of substance abuse treatment or concerning such treatment if the purpose is to initiate or substantiate any criminal charges against you or to conduct any investigation of you.

We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

We may disclose Protected Health Information to a coroner or medical examiner as authorized by law.

We may use or disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

We may use and disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

We may disclose Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs.

Revocation of Your Authorization

You may revoke Your Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement.

Your Individual Privacy Rights

Right to Request Additional Restrictions

You may request restrictions on our use and disclosure of Protected Health Information for treatment, payment and health care operations, to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.

If you wish to request additional restrictions, please obtain a request form from our Privacy Officer and submit the completed form to the Privacy Office. We will send you a written response.

Right to Receive Confidential Communications

You may request, and we will accommodate, any reasonable [written] request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

Right to Inspect and Copy Your Health Information

You may request access to your medical record 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, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge you $0.25 for each page.

Right to Amend Your Records

You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records.

If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office.

We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

Right to Receive an Accounting of Disclosures

Upon request, you may obtain an accounting of certain disclosures of Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.

If you request an accounting more than once during a twelve (12) month period, we will charge you $0.25 per page of the accounting statement.

Right to Receive Paper Copy of this Notice

Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

Further Information and How to File a Complaint

If you desire further information about your privacy rights, are concerned that we may have violated your privacy rights, or disagree with a decision that we made about access to Protected Health Information, you may contact our Privacy Officer.

You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services.

Upon request, the CCMH Privacy Officer will provide you with the correct address for the Director of the Office of Civil Rights.

We will not retaliate against you if you file a complaint with us or the Director of the Office of Civil Rights.

Effective Date and Duration of This Notice

This Notice is effective on April 14, 2003.

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 for 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 waiting areas around CCMH facilities and on our Internet site at www.ccmh1.com. You also may obtain any new notice by contacting the Privacy Office.

Privacy Officer

You may contact the CCMH Privacy Officer at:

Columbia Community Mental Health

Attention: Privacy Officer

58646 McNulty Way

St Helens, Oregon 97051

Telephone Number: (503) 397-5211 x231