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THIS NOTICE
DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET A COPY
OF THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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If
you have any questions or if you do not understand any part
of this Privacy Notice, please call our Privacy Officer at 609-463-0014
Ex. 20.
This notice is to help you to understand what is your health
information, how we may use it and share it with others and
it briefly describes what your rights are. We are required by
law to give you this notice. Within certain limits, we must
also maintain your privacy about your medical information. This
notice will describe for you examples of how your information
may be used or shared.
Health information includes identifying information (name, date
of birth, social security number, address, diagnosis, medications
prescribed) that we have received from you or other health care
providers. It may include information about your past, present
or future physical and/or mental health or condition. It may
also concern how you received health care treatment and the
type of payment received in the past, present or future for
your health care services. |
| All
Cape Counseling Services, sites and locations follow the
terms of this notice. All Cape Counseling Services, programs,
sites, and locations may share health information with
each other for treatment, payment or organization operations
as described in this notice. This notice also applies
to the following: |
- Any
service provider authorized to enter or review information
in your records.
- All
Cape Counseling Services departments and units.
- All
employees, staff and other paid company personnel.
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Privacy
Policy Pledge:
We understand that your health information is personal and we want to protect your privacy. Our records will have information about you such as, your appointments, your planned treatment, services you receive, modalities used, progress, your insurance information, etc. We need this information to provide you with care and receive payment for the services we provide. The information that you provide to us is confidential and private within the requirements of various state and federal laws. Release of this information for purposes other than conducting business or providing treatment within this organization require that you sign an authorization for the release of the information. We cannot and will not release any information without such a release. Children over the age of 14 require an authorization for the release of information that is signed by the minor, before a staff member can discuss their case with their parents. |
| By
law we are required to: |
- Keep
your medical information private.
- Provide
you with a notice of our duties and policies concerning
your personal data.
- Comply
with the policies protecting your personal data.
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I.
How your Personal Health Information may be used:
We may request, use and share your health information for
several reasons:
We may use your health information within Cape Counseling
Services, to provide and manage your treatment, to receive
payment for your treatment, and for our organization operations
including the review of client care and areas to improve.
Uses
of information not described in this notice will mostly be
made with your written permission, called an “authorization”.
You have the right to change or to take back your written
authorization at any time. To “revoke”
or to change your authorization, you may do the following.
Contact your Cape Counseling Services professional, to discuss
your situation and how it will affect your treatment. You
may then complete a Revocation of Authorization to Release
Protected Health Information form. Please be advised
that we are unable to take back any information we have already
released with your permissionn.
We
will obtain your signed consent to communicate with insurance
providers for payment of the services you receive from us.
This information is found on the Cape Counseling Services
Charge Slip that we use for billing purposes.
In most instances when we need to share PHI with a third party
we will seek your written permission. There are times when
CCS is permitted or required by law to use and disclose your
health information without specific consent from you, as described
in each category listed below.
We may use and share your health information without your
permission or opportunity to refuse under some special situations.
Examples are as follows:
a.
Emergencies. - We may use and share your information in an
emergency treatment situation.
b.
As required by law. - We will share information about you
when required by federal, state or local law.
c.
To lessen or prevent a serious threat to health or safety.
We may share information about you when necessary if there
is a threat to your health or safety or to the public’s
health or safety. We will only share information with someone
who is able to help prevent or lessen this threat.
d.
Public Health Activities. We may share information about you
as necessary for Public Health activities such as the following:
| i.
Report of death;
ii. Report of abuse, neglect or domestic violence
as required by law;
iii. Report to public health authorities to
control or prevent disease, injury or disability; |
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| e.
Health Oversight Activities. Oversight agencies include
government agencies that manage the health care system
and civil rights laws. We may share the following information. |
- Reports
as required by law to government programs such as
the Division of Mental Health or the Office of Legislative
Services for monitoring of our company
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| f.
Legal Proceedings and Law Enforcement Activities. We
may share health information with law enforcement officials
for specific purposes such as: |
- A
court order or if a similar legal process requires
us to do so.
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g.
Protective Services for Government Officials, National Security
and Intelligence Activities. We may release health information
to authorized federal officials for intelligence, security
and protective services as authorized by law.
h.
Research. We may share your health information with Cape Counseling
Services researchers only when the Executive Leadership and
Governing Board of Directors has approved their research.
The privacy board will ensure that the research protects your
private health information.
II.
Your Rights Regarding Your Health Information:
- You
have the right to ask to inspect or copy
your health information that has been used to make decisions
about your care. Under some circumstances we may deny
your request to inspect or copy your information. To exercise
this right please complete the Client Request to Copy/Read
Private Health Information. Any staff member can
give you a copy. Mail this notice to the Privacy Officer
Cape Counseling Services, 217 N. Main Street, Cape May
Court House, NJ 08210
- You
have the right to amend or change any
health information used to make decisions about your care.
To request a change of your health information, you must
complete a Client Request to Amend Private Health
Information Form. You may obtain the from a Cape
Counseling Services staff person. In the form, tell us
why you believe the information is incorrect. Upon completion,
return it to a Cape Counseling Privacy Officer at Cape
Counseling Services, 217 N. Main Street, Cape May Court
House, NJ 08210 for follow up. Be advised, we may deny
your request for amendment if you ask us to amend information
that:
- Was
not created by us, unless the person or party that
created the information is no longer available to
make the amendment;
- Is
not part of the information kept by our facility;
- Is
not part of the information which you would be permitted
to inspect or copy, or
- Is
accurate and complete.
- You
have the right to request restrictions, meaning
you may tell us who you do not want information released
to. To request a restriction, you must complete a Request
for Restriction form which any staff member can you
give to you and send it to our Privacy Officer at Cape
Counseling Services , 217 N. Main Street, Cape May Court
House, NJ 08210., and tell us how you want the information
restricted. We are not required to agree to a restriction
that is needed to provide you with emergency care. We
may also deny an amendment if it is not in writing or
does not include a reason to support the request. We may
also deny your request if you ask us to amend information
that was not created by us, or if the information is not
part of the information, which you would be permitted
to inspect and copy.
- You
have the right to request an “Accounting
of Disclosures.” This is a list of the
health information outside of treatment, payment or operations
that we have released to another source about you. To
request this list or accounting of disclosures, you must
contact your CCS professional to obtain a Request
for Accounting of PHI Disclosed by CCS form. Review
the form with the Cape Counseling Services staff person,
complete it and return it to the Privacy Officer, Cape
Counseling Services, 217 N. Main Street, Cape May Court
House, NJ 08210. Be advised that we cannot account for
any time periods that are beyond six years or that include
dates before April 14, 2003. Note that by law we are not
required to account for disclosures that you have given
written permission or authorization for the release of
information.
- You
have the right to request that we communicate in a confidential
manner with you about medical matters, such as only at
home, or work, etc.
- You
have the right to receive a paper copy of this Privacy
Notice at any time. To receive a copy, please contact
our Privacy Officer at 609-463-0014 Ex. 20
COMPLAINTS
If you believe your privacy rights have been violated, you
may file a complaint with Cape Counseling Services or with
the Secretary of the Department of Health and Human Services.
To file a complaint with Cape Counseling Services, please
contact the Privacy Officer in writing at Cape Counseling
Services, 217 N. Main St. Cape May Court House, NJ 08210.
All complaints must be sent in writing to the Privacy Officer.
You will never be punished or penalized for filing a complaint.
WE MAY CHANGE THIS NOTICE
We have the right to make changes in this notice effective for
health information we already have about you as well as any
information we may receive in the future. We will post a copy
of the current notice in all of our Cape Counseling Services
facilities. The notice will contain on the first page, in the
top right hand corner, the effective date. In addition, each
time you register at or are admitted to Cape Counseling Services
for treatment we will offer you a copy of the current notice
in effect. If you have a question about this notice, please
call the Privacy Officer at 609-463-0014 ex. 20.
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