This notice describes:
You have a right to a copy of this notice, in paper or electronic form, and to discuss it with [ENTER NAME OR TITLE] at [PHONE AND EMAIL] if you have any questions.
In this notice, your health information means your substance use disorder patient record.
You have the right to:
With your consent, we can use and share your information as we:
We may use and share your information without your consent as we:
In all these circumstances, we must protect your information and limit how we use and share it.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes.
[Suggested optional language:] You may provide consent for more limited purposes for example, to only disclose information to another health care provider for your treatment; however, doing so may affect the services we can provide you or how you pay for services.
[Suggested optional language:] You may provide a general consent to share your information through certain third parties, such as a health information network or a research institution, where your treating health care providers can access it.
You can ask us not to use or share certain health information for treatment, payment, or our health care operations after you have provided consent for all those purposes. We are not required to agree to your request, and we may say “no” if, for example, it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our health care operations with your health insurer. We will say “yes” unless a law requires us to share that information.
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
You can ask questions or obtain more information about this notice and our privacy practices by calling or emailing the contact person at the top of this notice.
You have the right to a clear and obvious notice in advance of, and a choice about whether to receive, fundraising communications for our program.
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html .
We will not retaliate against you for filing a complaint.
With your consent, we typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for a chronic condition asks a doctor at our program about your health condition and medications you are taking, for example, to avoid complications.
We can use and share your health information to run our program, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
With your consent, we may also use and share your information in the following ways:
If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
We are allowed or required to share your information in certain ways without your consent – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
We can share your information within our program, with an organization that has administrative control over our program, and with contractors who help us run our program.
We can share your information during a bona fide medical emergency with the personnel and health care providers responding to your emergency, even when you are unable to consent because of the emergency.
We can also share your identifying information to assist the federal Food and Drug Administration in notifying you or your doctor about unsafe products you may be using.
We can share health information that does not identify you for certain situations such as:
We can use or share your information to conduct or help with health research. Researchers cannot include any patient identifying information in their reports about the research.
We can use or share your information to improve the quality of our services, obtain needed credentials, and cooperate with oversight agencies for activities authorized by law, as long as those who view or receive the information agree to destroy or return the information when they are finished and agree not to use it against you.
We can share patient identifying information about a deceased patient as required or allowed by laws that collect information relating to cause of death.
We will only report the information required by law.
We may report to law enforcement when a patient commits or threatens to commit a crime within our program or against our staff.
When you consent to uses and disclosures for all future treatment and payment purposes and to run our business, we may share your information with other substance use disorder treatment programs, doctors’ offices, and health care businesses for those activities. If the person who receives it is subject to HIPAA, then they are allowed to use and share your information again without your consent for the purposes that HIPAA allows. Your information still cannot be used in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a subpoena or similar legal requirement.
We must follow certain procedures before using or sharing your information for investigations and legal proceedings.
We will not use or share your information or provide testimony about your information in any civil, administrative, criminal, or legislative proceedings against you without your written consent or a court order.
We will only respond to a court order to use or share your health information if it is accompanied by a subpoena or other similar legal mandate requiring us to comply.
We will only use or share your information in proceedings against you based on a court order after we have received notice and an opportunity to be heard or you tell us that you have received notice.
We may use or share your information to respond to legal proceedings against our program based on a court order and you may not be notified in advance. You have the right to seek to overturn or change the court order after you learn about it.
We are required to follow the terms of this notice that are currently in effect. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our website.
This notice is effective as of [insert effective date of this notice].
Insert name or title of the privacy contact and his/her email address and phone number.
Insert any special notes that apply to your entity’s practices such as, “We will provide you with a summary of your treatment history upon request.”
Part 2 requires you to describe any state or other laws that require greater limits on disclosures. For example, “The information we can share about you for treatment is limited to admission forms, treatment/discharge forms, and discharge summaries.” Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.
