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FAIRBANKS PRIVACY NOTICE
(Effective April 1, 2003)
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.
OUR PLEDGE TO YOU. Your health information, which means any written or oral information that we create or receive that describes your health condition, treatment or payments is personal. Therefore, Fairbanks as an Organized Health Care Arrangement, its medical staff and personnel, pledge to protect your health information as required by law. We give you this Privacy Notice to tell you (1) how we will use and disclose your "Protected Health Information" or PHI; and (2) how you can exercise certain individual rights related to your PHI as a patient of Fairbanks. Because we qualify as a alcohol and drug abuse treatment program under 42 CFR Part 2, Fairbanks must comply with additional federal regulations that establish special safeguards to protect the confidentiality of your PHI and any Uses and Disclosures by Fairbanks that are described in Section 1 of this Privacy Notice. Pursuant to those regulations you will receive a separate summary of the Federal law and regulations. We reserve the right to change our practices and to make the new provisions effective for all protected heath information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied.
- How We Will Use And Disclose Your PHI
- To Provide Treatment.
We may use and disclose your PHI, to the extent permitted by law, to provide, coordinate, and manage your health status, your health care and any related services to be received from another health care provider. For example, we may disclose your PHI to fill a prescription or to order laboratory tests. We may also disclose your PHI to another physician who may be treating you or consulting with us regarding your care.
- To Obtain Payment.
We may also use and disclose your PHI to the extent permitted by law, as needed, to obtain payment for services that we provide to you. This may include certain communications to your health insurer or health plan to confirm (1) your eligibility for health benefits; (2) the medical necessity of a particular service; or (3) any prior authorization or utilization review requirements. We may also disclose your PHI to another provider involved in your care for the provider's payment activities. For example, this may include referral sources such as EAPs, and we may include disclosure of demographic information to another health care provider who is involved in your care for payment purposes.
- To Perform Health Care Operations.
We may also use or disclose your PHI, to the extent permitted by law, as necessary, to carry out our daily health care operations, and to provide quality care to all of our patients. These health care operations may include such activities as: quality improvement; medical staff and employee reviews; health professional training programs, including those in which students, trainees, or practitioners in health care learn under supervision; accreditation; licensing or credentialing activities; compliance reviews and audits; defending a legal or administrative claim; business and management development; and other administrative activities.
- To Contact You.
To support our treatment, aftercare, payment and health care operations, we may also contact you, either by telephone or mail, from time to time to (1) remind you of an upcoming appointment date; (2) inform you of potential treatment options and services that may be of interest to you; (3) follow up with you on your progress after treatment for the purpose of determining our treatment outcomes; (4) to inform you of new Fairbanks services and products that may be available to you, unless you request in writing to use alternative means to contact you.
- To Conduct Fund-raising Activities.
From time to time, certain parts of your PHI, specifically your name, address, telephone number and dates of services, may be used by Fairbanks to contact you in order to raise money for the organization and our various programs. Certainly, you may choose to "opt out" of any such fund-raising activities at any time by notifying Fairbanks in writing.
- To Conduct Research.
Under certain circumstances, we may use and disclose your PHI to researchers for research purposes, but only if the research is related to your treatment and is approved by an Institutional Review Board or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI. Other forms of research will require your express written authorization.
- Business Associates.
There are some services provided in our facility through contracts/agreements with business associates. Examples include but may not be limited to laboratory testing, pharmacy, x-ray, EKG and emergency room. When these services are contracted, we may disclose your PHI to our business associates so they can provide the contracted services on behalf of Fairbanks and obtain payment. To protect your PHI, however, we require the business associates to enter into a written contract that requires them to appropriately safeguard your PHI.
- According to Laws That Require or Permit Disclosure.
Certain laws may require or permit Fairbanks to disclose your PHI, but only under specific circumstances, as follows:
- When There Are Risks to Public Health.
We may disclose your PHI to (1) report disease, injury or disability; (2) report vital events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and defects; (5) notify appropriate persons regarding communicable disease concerns; (6) notify health officials in the event we believe, in good-faith, that there is a serious or imminent threat to your health and safety and of the health and safety of others.
- To Report Suspected Child/Elder Abuse/Neglect.
We may notify government authorities and may release some of your PHI in the event of suspected child abuse, or with the victim's permission, elder abuse/neglect.
- To Conduct Health Oversight Activities.
We may disclose your PHI to a health oversight agency for activities including audits, civil, administrative, or criminal investigations, proceedings, or actions, inspections, licensure or disciplinary actions; or other activities necessary for appropriate oversight.
- Workers Compensation.
We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
- For Law Enforcement Purposes.
We may disclose your PHI to law enforcement officials (1) as required by a properly executed court order; (2) in the event a crime is committed by you against this organization or against any person who works for this organization or you have made threats to commit such a crime.
- In Connection with Judicial and Administrative Proceedings.
We may disclose your PHI in the course of a judicial or administrative proceeding, but only with your prior express written authorization, or a court order issued by a court of competent jurisdiction.
- With Your Prior Express Written Authorization.
Other than for the purposes (A) through (H) stated above, we will not disclose your PHI without first obtaining your express written authorization. Please note that you may revoke a particular authorization at any time, orally or in writing, except to the extent that we have taken action in reliance upon the authorization.
- Your Individual Rights Concerning Your PHI
- The Right to Inspect and Copy Your PHI.
You may inspect and obtain a copy of your PHI that we have created or received as we provide your treatment or obtain payment for your treatment. Under federal law, however, we reserve the right to deny inspection and copies of psychotherapy notes if we feel it is in your best interest. You may not inspect or receive a copy of information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, or for PHI that is subject to a law prohibiting access. Depending on the circumstances, you may have the right to request a second review if we deny your request to access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm to another person referenced within the information. As before, you have the right to request a second review of this decision. To inspect and copy your PHI, you must submit a written request to the Medical Records Department. We have 30 days to comply with your request and we may charge you a fee for the reasonable costs that we incur in processing your request.
- The Right to Request Restrictions on How We Use and Disclose Your PHI.
You may ask us to restrict how we use or disclose your PHI for treatment, payment and health care operations, as described previously. This is in addition to your consents for mutual disclosure to third parties for disclosures of your PHI that does not fall under treatment, payment, or health care operations. To request a restriction please submit requests in writing to Fairbanks. Please note that we are only required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will communicate and comply with your request, except in the case of an emergency. Under certain circumstances, we may choose to terminate our agreement to a restriction if it becomes too burdensome to carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions after your visit by contacting the Medical Records Department directly.
- The Right to Request Amendments To Your PHI.
You may request that your PHI be amended so long as it is a part of our designated record set. All such requests must be in writing and directed to our Medical Records Department. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may respond to your statement in writing and provide you with a copy.
- The Right to Receive an Accounting.
You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other than those for treatment, payment and health care operations, which are specified in sections (A-C) above. The accounting is not required to report PHI disclosures (1) to family members or health care providers involved in your treatment or (2) to third party payors, insurance and health plans, or (3) that we are otherwise required or permitted to make by law. As before, your request must be made in writing to our Medical Records Department. The request should specify the time period, but please note that we are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. 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.
- The Right to File A Complaint.
You have the right to contact our Privacy Officer at any time if you have questions, comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also have the right to contact the Department of Health and Human Services, in Washington D.C., regarding these privacy matters, particularly if you do not believe that we have been responsive to your concerns. In any case, we urge you to contact our Privacy Officer if you have any questions, comments or complaints, either in writing or by telephone. The contact information for our Privacy Officer is as follows:
Privacy Officer
Fairbanks
8102 Clearvista Parkway
Indianapolis, IN 46256
317-849-8222 or toll free 800-225-4673
Please note that we will not take any action or otherwise retaliate against you in any way as a result of your communications to our Privacy Officer or to the Department of Health and Human Services. As always, please feel free contact us. We look forward to serving you.
Thank you very much.
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