OPTIONS FOR SOUTHERN OREGON, INC.
NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003
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.
You may request to have this form made available in other languages and alternate formats that meet the guidelines for the Americans with Disabilities (ADA).
Options for Southern Oregon, Inc. (Options) provides many types of mental health services. Options staff must collect information about you to provide these services. Options is required to protect this information by Federal and State law. We call this information “protected health information” (PHI).
The notice of privacy practices will tell you how Options may use or disclose information about you. Not all situations will be described. Options is required to give you a notice of our privacy practices for the information we collect and keep about you. Options is required to follow the terms of the notice currently in effect.
Options May Use and Disclose Information Without Your Authorization
· For Treatment. Options may use or disclose information with health care providers who are involved in your health care. For example, information may be shared to create and carry out a plan for your treatment.
· For Payment. Options may use or disclose information to get payment or to pay for the health care services you receive. For example, Options may require PHI to bill your health plan for health care provided to you.
· For Health Care Operations. Options may use or disclose information in order to manage its programs and activities. For example, Options may use PHI to review the quality of services you receive.
· Appointments and Other Health Information. Options may send you reminders for medical care or checkups. Options may send you information about health services that may be of interest to you.
· For Mental Health Oversight Activities. Options may use or disclose information to inspect or investigate health care providers.
· As Required by Law and for Law Enforcement. Options will use and disclose information when required or permitted by federal or state law or by a court order.
· For Abuse Reports and Investigations. Options is required by law to receive and investigate reports of abuse.
· For Government Programs. Options may use and disclose information for public benefits under other government programs. For example, Options may disclose information for the determination of Supplemental Security Income (SSI) benefits.
· To Avoid Harm. Options may disclose PHI to law enforcement in order to avoid a serious threat to the health and safety of a person or the public.
· For Research. Options uses information for studies and to develop reports. These reports to not identify specific people.
· Disclosures to Family, Friends, and Others. Options may disclose information to your family or other persons who are involved in your medical care. You have the right to object to the sharing of this information.
Other Uses and Disclosures Require Your Written Authorization
· For other situations, Options will ask for your written authorization before using or disclosing information. You may cancel this authorization at any time in writing. Options cannot take back any uses or disclosures already made without your authorization.
· Other Laws Protect PHI. Many Human Resource programs have other laws for the use and disclosure of information about you. For example, you must give your written authorization for Options to use and disclose your mental health and chemical dependency treatment records.
Your PHI Privacy Rights
When information is maintained by Options as a public health agency, the public health records are governed by other State and Federal laws and is not subject to the rights described below.
· Right to See and Get Copies of Your Records. In most cases, you have the right to look at or get copies of your records. You must make the request in writing. You may be charged a fee for the cost of copying your records.
· Right to Request to Correct or Update Your Records. You may ask Options to change or add missing information to your records if you think there is a mistake. You must make the request in writing, and provide a reason for your request.
· Right to Get a List of Disclosure. You have the right to ask Options for a list of disclosures made after April 14, 2003. You must make the request in writing. This list will not include the times that information was disclosed for treatment, payment, or health care operations. The list will not include information provided directly to you or your family, or information that was sent with your authorization.
· Right to Request Limits on Uses or Disclosures of PHI. You have the right to ask that Options limit how your information is used or disclosed. You must make the request in and tell Options what information you want to limit and to whom you want the limits to apply. Options is not required to agree to the restriction. You can request that the restrictions be terminated in writing or verbally.
· Right to Revoke Permission. If you are asked to sign an authorization to use or disclose information, you can cancel that authorization at any time. You must make the request in writing. This will not affect information that has already been shared.
· Right to Choose How We Communicate With You. You have the right to ask that Options share information with you in a certain way or in a certain place. For example, you may ask Options to send information to your work address instead of your home address. You must make this request in writing. You do not have to explain the basis for your request.
· Right to File a Complaint. You have the right to file a complaint if you do not agree with how Options has used or disclosed information about you.
· Right to Get a Paper Copy of This Notice. You have the right to ask for a paper copy of this notice.
How to Contact Options to Review, Correct or Limit Your Protected Health Information (PHI)
You may contact the Options office or the Options Compliance Office at the address listed at the end of this notice to:
· Ask to look at or copy your records
· Ask to limit how information about you is used or disclosed
· Ask to cancel your authorization
· Ask to correct or change your records
· Ask for a list of the times Options disclosed information about you.
Options may deny your request to look at, copy or change your records. If Options denies your request, you will be sent a letter that tells you why your request is being denied and how you can ask for a review of the denial. You will also receive information about how to file a complaint with Options or with the U.S. Department Health and Human Services, Office for Civil Rights.
Options Will Notify You If a Breach of Your Information Occurs
Options will notify you if your unsecure personal health information is breached. Options will make the notification without unreasonable delay and in any event within 60 days of discovery. You will be notified of the circumstances of the breach, date of the breach, date of discovery, personal health information involved, steps needed to mitigate harm, and where you can obtain additional information.
Notice of Privacy Practice
For Your Information
In the future, Options for Southern Oregon, Inc. may change its Notice of Privacy Practices. Any changes will apply to information Options for Southern Oregon, Inc. already has, as well as any information Options for Southern Oregon, Inc. receives in the future. A copy of the new notice will be posted at each Options for Southern Oregon, Inc. facility and provided as required by law. You may ask for a copy of the current notice anytime you visit and Options for Southern Oregon, Inc. facility or visit our website at Optionsonline.org.
How to File a Complaint or Report a Problem
You may contact any of the people listed below if you want to file a complaint or to report a problem with how Options has used or disclosed information about you. Your benefits will not be affected by any complaints that you make. Options cannot retaliate against you for filing a complaint, cooperating in an investigation, or refusing to agree to something that you believe to be unlawful.
Options for Southern Oregon, Inc.
1215 SW ‘G’ Street
Grants Pass, OR 97526
Phone: 1 (541) 476-2373 Fax: 1 (541) 476-1526 Email: email@example.com
State of Oregon Department of Human Services
Governor’s Advocacy Office
522 Summer St. NE, E17
Salem, OR 97301-1097
Phone: 7-900-442-5238 Fax: 1 (503) 378-6532 Email: GAO.info.state.or.us
Office of Civil Rights
Medical Privacy, Complaint Division
U.S. Department of Health and Human Services
200 Independence Avenue, SW, HHH Building, Room 509H
Washington, D.C. 20201
Phone: 866-627-7748 TTY: 7886-788-4989 Email: www.hhs.gov/ocr