Notice Regarding The Use And Disclosure Of
Protected Health Information
Effective September 23, 2013
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.
This notice describes how Mental Health Services for Clark and Madison Counties, Inc. ("MHSCMC") uses or discloses
your PHI ("PHI"). PHI is information that identifies you and relates to health care services, the payment of health care services or
your physical or mental health or condition, in the past, present or future. This notice also describes your rights to access and control
Federal law requires that we maintain the privacy of your PHI and provide to you this Notice of our legal duties and privacy practices. We
are required to notify affected individuals following a breach of unsecured PHI. We are required to abide by the terms of this Notice, which
may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for
all PHI that we maintain. We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures,
your rights, our duties, or other practices stated in this Notice. Except when required by law, a material change to this notice will not be
implemented before the effective date of the new notice in which the material change is reflected.
How We May Use or Disclose PHI For Treatment, Payment, and Health Care Operations
For Treatment. We may use and disclose your PHI to coordinate or manage your care within our organization and also with
individuals or organizations outside of our organization that are involved in your care, such as your primary therapist, other health care
professionals, contracted service providers or related organizations. For example, your counselor could share with your treating physician that
you are depressed. The physician could then prescribe medication to make you feel better.
To Obtain or Provide Payment. We may include your PHI in invoices to collect or provide payment to or from third parties for
the care you receive through MHSCMC. For example, we could send PHI to your insurance company or to the Ohio Department of Medicaid stating
when and for what condition you were in the office to obtain payment for the services provided to you.
To Conduct Health Care Operations. We may use and disclose PHI for our own operations and as necessary to provide quality care
to all of our service recipients. Health care operations includes but is not limited to the following activities: quality assessment and
improvement activities; activities designed to improve health or reduce health care costs; protocol development, case management and care
coordination; professional review and performance evaluation; review and auditing, including compliance reviews, medical reviews, legal services
and compliance programs; and business management and general administrative activities of MHSCMC. For example, we may use PHI to evaluate our
staff performance or combine your health information with other consumer PHI to evaluate how to better serve all of our consumers. Another
example may be the disclosure of your PHI to staff or contracted personnel for certain limited training purposes.
How We May Use or Disclose PHI For Appointment Reminders, Treatment Alternatives, or Fundraising Activities
We may use and disclose your PHI to contact you as a reminder that you have an appointment. We may use and disclose your PHI to advise you or
recommend possible service options or alternatives that may be of interest to you. We may contact you for fundraising activities. However,
you will be provided the opportunity to opt out of receiving such fundraising communications.
Disclosures You May Authorize Us to Make
We will not use or disclose your PHI without authorization, except as described in this Notice. Most uses and disclosures of psychotherapy notes,
as applicable, require your authorization. Subject to certain limited exceptions, we may not use or disclose PHI for marketing without your
authorization. We may not sell PHI without your authorization. You may give us written authorization to use and/or disclose PHI to anyone for
any purpose. If you authorize us to use or disclose such information, you may revoke that authorization in writing at any time.
Other Specific Uses or Disclosures
When Legally Required. We will disclose your PHI when required by any Federal, State or local law.
In the Event of a Serious Threat To Life, Health Or Safety. We may, consistent with applicable law and ethical standards of conduct,
disclose your PHI if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to your life,
health, or safety, or to the health and safety of the public
When There Are Risks to Public Health. We may disclose your PHI for public activities and purposes allowed by law in order to prevent
or control disease, injury or disability; report disease, injury, and vital events such as birth or death; conduct public health surveillance,
investigations, and interventions; or notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading
To Report Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe a consumer is the victim of abuse,
neglect or domestic violence. We will make this disclosure only when required or authorized by law, or when the consumer agrees to the disclosure
To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits, civil
administrative or criminal investigations, inspections, licensure or disciplinary action. However, we may not disclose your PHI if you are the subject
of an investigation and your PHI is not directly related to your receipt of health care or public benefits
In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative
proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order, or, in response to a subpoena, discovery
request or other lawful process, if we determine that reasonable efforts have been made by the party seeking the information to either notify you about
the request or to secure a qualified protective order regarding your health information. Under Ohio law or 42 C.F.R. Part 2, some requests may require
a court order for the release of any confidential medical information.
For Law Enforcement Purposes. As permitted or required by law, we may disclose specific and limited PHI about you for certain law
For Research Purposes We may, under very select circumstances, use your PHI for research. Before we disclose any of your PHI for such
research purposes in a way that you could be identified, the project will be subject to an extensive review and approval process, unless otherwise
prohibited as with Medicaid.
For Specified Government Functions. Federal regulations may require or authorize us to use or disclose your PHI to facilitate specified
government functions relating to military and veterans; national security and intelligence activities; protective services for the President and others;
medical suitability determinations; and inmates and law enforcement custody.
For Workers’ Compensation. We may use or disclose your PHI for workers’ compensation or similar programs.
Transfer of Information at Death. In certain circumstances, we may disclose your PHI to funeral directors, medical examiners, and
coroners to carry out their duties consistent with applicable law.
Organ Procurement Organizations. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other
entities engaged in the procurement, banking, or transplantation of organs for the purposes of tissue donation and transplant.
Your Rights with Respect to PHI
You have the following rights regarding PHI that we maintain:
Right to a Personal Representative. You may identify persons to us who may serve as your authorized personal representative, such as a
court-appointed guardian, a properly executed and specific power-of-attorney granting such authority, a Durable Power of Attorney for Health Care if it
allows such person to act when you are able to communicate on your own, or other method recognized by applicable law. We may, however, reject a
representative if, in our professional judgment, we determine that it is not in your best interest.
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the
right to request a limit on our disclosure of your PHI to someone who is involved in your care or the payment of your care. Although we will consider
your request, please be aware that we are under no obligation to accept it or to abide by it unless the request concerns a disclosure of PHI to a health
plan for purposes of carrying out payment or health care operations, and the PHI pertains solely to a health care service for which the provider has
been paid out of pocket in full. To request such restrictions, please contact Medical Records Department, Mental Health Services for Clark and Madison
Counties, Inc., at 937-399-9500.
Right to Receive Confidential Communications. You have the right to request that we communicate with you in a confidential manner. For
example, you may ask us to conduct communications pertaining to your health information only with you privately, with no other family members present.
If you wish to receive confidential communications, please contact the Director of Quality, Mental Health Services for Clark and Madison Counties, Inc.,
at 937-399-9500. We may not require that you provide an explanation for your request and will attempt to honor any reasonable requests.
Right to Inspect and Copy Your PHI. Unless your access to your records is restricted for clear and documented treatment reasons, you have
a right to see your PHI upon request. You have the right to inspect and copy such health information, including billing records, at a reasonable time
and place. A request to inspect and copy records containing your PHI may be made to Medical Records Department, Mental Health Services for Clark and
Madison Counties, Inc., at 937-399-9500. If you request a copy of such health information, we may charge reasonable copying, processing, and personnel
fees. If the PHI that is the subject of a request is maintained in one or more designated record sets electronically and if you request an electronic
copy of such information, we will provide you with access to the PHI in the electronic form and format requested if readily producible in such form and
format; or, if not, in a readable electronic form and format as agreed upon by us and you.
Right to Amend Your PHI. You have the right to request that we amend your records, if you believe that your PHI is incorrect or incomplete.
That request may be made as long as we maintain the information. A request for an amendment of records must be made in writing to Medical Records
Department, Mental Health Services for Clark and Madison Counties, Inc., 474 N. Yellow Springs Street, Springfield, OH 45504.
We may deny the request if it is not in writing, or does not include a reason for the amendment. The request also may be denied if your health information
records were not created by us, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of
the health information you are permitted to inspect and copy, or if, in our opinion, the records containing your health information are accurate and
complete. We take the position that amendments may take the form of including a written statement from you and may not include changing, defacing or
destroying any necessary information related to your health care.
Right to Know What Disclosures Have Been Made. You have the right to request an accounting of disclosures of your PHI made by us for certain
reasons, including reasons related to public purposes authorized by law, and certain research. The request for an accounting must be made in writing to
Medical Records Department, Mental Health Services for Clark and Madison Counties, Inc., 474 N. Yellow Springs Street, Springfield, OH 45504. The request
must specify the time period for the accounting, and may not be made for periods of time in excess of six (6) years prior to the date on which the
accounting is requested. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may
be subject to a reasonable, cost-based fee.
Right to a Paper Copy of This Notice. You have a right to receive paper copy of this Notice at any time, even if you have received this
Notice previously. To obtain a paper copy, please contact Medical Records Department, Mental Health Services for Clark and Madison Counties, Inc., at
Where to File a Complaint
You have the right to complain to us if you believe that your privacy rights have been violated, including the denial of any rights set forth in this Notice.
Any complaints to us shall be made in writing to the Director of Quality, Mental Health Services for Clark and Madison Counties, Inc., 474 N. Yellow
Springs Street, Springfield, OH 45504. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be
retaliated against in any way for filing a complaint.
You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C.,
20201 or call toll-free (877) 696-6775, by e-mail to OCR Complaint @ hhs.gov, or to Region V, Office for Civil Rights, U.S. Department of Health and Human
Services, 233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312) 886-1807, or TDD (312) 353-5693.
We have designated the Privacy Official as our contact point for all issues regarding consumer privacy and your rights under this Notice. If you have any
questions regarding this Notice, please contact the Manager of Information Systems, Mental Health Services for Clark and Madison Counties,Inc., 474 N. Yellow
Springs Street, Springfield, OH 45504. at 937-399-9500.
If You Have Any Questions Regarding This Notice, please contact the Manager of Information Systems, Mental Health Services for Clark and Madison Counties, Inc.,