NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

OUR RESPONSIBILITY

Counseling Associates, Inc. commits to:

• maintain the security and privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice, until such time as our privacy practices or the law changes
• notify you if we are unable to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our privacy practices and the terms of this Notice at any time.

This Notice takes effect 4/13/03 and will remain in effect until we replace it.

Each time you receive health care services from Counseling Associates, Inc., a record of your service is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment and a plan for further care or treatment. This information, often referred to as your health or medical records serves as a:

• basis for planning your care or treatment
• means of communication among the many health professionals who contribute to your care
• legal document describing the care your receive
• means by which you or a third-party payer can verify that services billed are actually provided
• a tool in educating health professionals, clinical and support staff
• a source of information for public health officials charged with improving the health of the nation (communicable diseases)
• a source of data for facility planning and marketing
• a tool with which we can assess and continually work to improve the care we render and outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

• ensure its accuracy
• better understand who, what, when, where and why others may access your health information
• make more informed decisions when authorizing disclosure by others

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YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of Counseling Associates, Inc., or the facility that compiled it, the information belongs to you. You have the right to:

• request restrictions on certain uses and disclosures of your information as provided by 45 CFR 164.522
• obtain a paper copy of the notice of information practices upon request
• inspect and copy (exception psychotherapy notes) as provided for in 45 CFR 164.524; (exception: Arkansas State Statute deems that if the information could be detrimental to the patient’s health, inspection and copy of the record can be denied) amend your health record as provided for in 45 CFR 164.528
• obtain an accounting of disclosures of your health information as provided for in 45 CFR 164.528
• request communications of your health information by alternative means or at alternative locations
• revoke your authorization to use or disclose health information except to the extent that action has already been taken.

USES AND DISCLOSURES OF HEALTH INFORMATION TREATMENT

Example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the treatment team will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in your treatment once you are discharged from this facility.

Payment
Example: A bill may be sent to you or a third-party payor. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Regular Health Operations of Counseling Associates, Inc.
Example: Members of the medical staff, the risk, compliance or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.

Business Associate
We provide some services through contracts with business associates. Examples include transcription services and data processing services. When these services are used, we may disclose your health information to the business associates so they can perform the function(s) we have contracted with them. To protect your health information, however, we require the business associates to appropriately safeguard your information.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Law Enforcement
We may disclose health information to law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Abuse or Neglect: As required by law, we may disclose your health information to appropriate authorities if we reasonably believe that child or elder abuse, neglect, or domestic violence has occurred. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

Public Health: We may disclose personal health information when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

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PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending a letter to the Health Information Manager where you received services. If you request copies, we will charge you $1.00 per page for the first 5 pages, then $0.25 per page thereafter, not to exceed $25.00.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we limit how we use or disclose your protected health information. CAI will consider your request, but we are not legally bound to agree to any requested restrictions.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. We will respond within 60 days of receiving your request.

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CONFIDENTIALITY OF ALCOHOL AND SUBSTANCE ABUSE PATIENT RECORDS

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless one of the following conditions is met: (1) the patient consents in writing; (2) the disclosure is allowed by a court order; (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws 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.

Other uses and disclosures will be made only with the individual’s written authorization and the individual may revoke such an authorization.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information, you may contact us:

You may also submit a complaint to the U.S. Department of Health and Human Services: (202) 619-027. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us.

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