This notice describes how protected health information about you may be used and disclosed and how you can get access to this information.
Please read carefully
Our Privacy Commitment to You
We care about your privacy. The information we collect about you is private. We are required to give you a notice of our privacy practices. Only people who have both the need and the legal right may see your information. Unless you give us permission in writing, we will only disclose your information for purposes of treatment, payment, business operations or when we are required by law to do so.
- Treatment: We may disclose medical information about you to coordinate your health care, for example, between your case manager and the CMH physician. We may also contact you about appointment reminders and treatment alternatives.
- Payment: We may use and disclose information so the care you get can be properly billed and paid. For example, sending billing information to a health insurance plan.
- Business: Operations We may need to use and disclose information for our business operations. For example, we may use information to review the quality of care you receive. We will not use your protected health information for marketing, fundraising or research without your permission.
- As Required By Law: We will release information when we are required by law to do so. Examples of such releases would be to law enforcement if you threaten to harm another person; reporting abuse, neglect or domestic violence; subpoenas or other court orders; communicable disease reporting; disaster relief; review of our activities by government agencies; national security purposes; or in other kinds of emergencies.
With Your Permission If you give us permission in writing, we may use and disclose your personal information. If you give us permission, you have the right to change your mind and revoke it. This must be in writing, too. We cannot take back any uses or disclosures already made with your permission.
Your Privacy Rights
You have the following rights regarding the health information that we have about you. Your requests must be made in writing to AuSable Valley Community Mental Health Authority.
- Your Right to Inspect and Copy: In most cases, you have the right to look at or get copies of your records in either paper or electronic format. You may be charged a fee for the cost of copying your records.
- Your Right to Amend: You may ask us to change your records if you feel that there is a mistake. We can deny your request for certain reasons, but we must give you a written reason for our denial.
- Your Right to a List of Disclosures: You have the right to ask for a list of disclosures made after April 14, 2003. This list will not include the times that information was disclosed for treatment, payment, or health care operations. The list may include information provided directly to you or your family, or information that was sent with your authorization.
- Your Right to Request Restrictions on Our Use or Disclosure of Information: You have the right to ask for limits on how your information is used or disclosed. We are not required to agree to such requests. You also have the right to request that we not send any protected health information to your insurance company if you pay for the total amount of any treatment service.
Your Right to Request Confidential Communications You have the right to ask that we share information with you in a certain way or in a certain place. For example, you may ask us to send information to your work address instead of your home address. You do not have to explain the basis for your request.
- Your Right to be Notified of Any Breaches in Confidentiality: We must notify you if it is determined that your protected health information has been shared inappropriately with others.
Changes to this Notice
We reserve the right to revise this notice. A revised notice will be effective for protected health information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever notice is currently in effect. If changes are material, a new notice will be mailed to you before it takes effect.
How to Use Your Rights Under This Notice
If you want to use your rights under this notice, you may call us or write to us. Your request to us must be in writing. We will help you prepare your written request if you wish.
- Complaints to the Federal Government
If you believe that your privacy rights have been violated, you have the right to file a complaint with the federal government. You may write to:
Office of Civil Rights
Dept. of Health and Human Services
233 N. Michigan Ave, Suite 240
Chicago, IL. 60601
You will not be penalized for filing a complaint with the federal government.
- Complaints and Communications to Us
If you want to exercise your rights under this notice or if you wish to communicate with us about privacy issues or if you wish to file a complaint, you can write to:
Privacy Officer AVCMHA
P.O. Box 310, Tawas City, MI 48764
You will not be penalized for filing a complaint.
Confidentiality of Alcohol and Substance
Use Information: If you receive substance use treatment, the confidentiality of your alcohol and substance use records maintained by AuSable Valley Community Mental Health Authority (AVCMHA) is protected by federal law and regulations. AVCMHA may not say to a person outside the program that you attend the program or disclose any confidential alcohol and substance use records unless:
- You consent in writing; or
- Disclosure is allowed by a court order; or
- The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or
- You commit or threaten to commit a crime either at the program or against any person who works for AVCMHA.
Violation of the federal law and regulations by AVCMHA is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.
Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
See 42 USC 290dd-2 for federal law and 42 CFR Part 2 for federal regulations governing Confidentiality of Alcohol and Substance Use Patient Records.
Copies of this Notice
You have the right to receive an additional copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. Please call or write to us to request a copy.
PRIVACY NOTICE Revised 8/13