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.
You will be asked to provide written
consent and authorization for specific uses of information about yourself.
If you have any
questions about this Notice please contact our office staff.
The Manlove
Psychiatric Group; DBA: Manlove Brain and Body Health (MBBH) is required by law
to maintain the privacy of protected health information and to provide
individuals with notice of its legal duties and privacy practices with respect
to protected health information. This Notice
of Information Practices describes how we may use and disclose your
protected health information to carry out treatment, payment, or health care
operations, and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health
information. These Practices are effective on April 14,
2003, and are not necessarily retroactive to prior actions of MBBH.
“Protected health information ” (PHI) is information
about you, including demographic and mental health information, that relates to
your past, present, or future physical or mental health or condition and related
health care services.
We are
required to abide by the terms of this Notice of Information Practices. We may
change the terms of our notice, at any time. The new notice will be effective
for all protected health information that we maintain at that time. Notice of
substantive revisions and/or modifications to the MBBH will be posted in the
waiting rooms at MPG. Upon your request, we will provide you with any revised Notice of Information Practices in
person or by calling the office and requesting that a revised copy be sent to
you in the mail. You may also ask for one at the time of your appointment.
Section 1. Uses and Disclosures of Protected Health Information (PHI)
Uses and Disclosures of Protected Health
Information Based Upon Your Written Consent/Authorization
You will be asked
to complete and sign a Manlove Brain and Body Health (MBBH) Patient
Information, Consent to Treatment and Authorization for Use of PHI form. Once
you have explicitly authorized the use and disclosure of your protected health
information for treatment, payment, and health care operations, we may use or
disclose your protected health information as described in this Section 1.
Following
are examples of the types of uses and disclosures of your protected health care
information that we are permitted to make once you have signed this form. These
examples are not meant to be exhaustive, but to describe the types of uses and
disclosures that may be made by our office once you have provided consent.
Treatment:
We may use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This includes
the coordination or management of your health care with a third party that has
already obtained your permission to have access to your protected health information.
For example, we would disclose your protected health information to other
health care providers who may be treating you when we have the necessary
permission from you to disclose your protected health information. For example,
your protected health information may be provided to another health care
provider to whom you have been referred to ensure that they have the necessary
information to diagnose or treat you. In addition, we may disclose your
protected health information from time-to-time to another health care provider
(e.g., a specialist or laboratory) who, at the request of your MBBH provider,
becomes involved in your care by providing assistance with your health care
diagnosis or treatment. If you believe you need a Language Interpreter, please
request a Consent Form for Use of Language Interpreter to complete.
Payment: Your protected
health information will be used to obtain payment for your health care
services. This may include certain activities that your health insurance plan
may undertake before it approves or pays for the health care services we
recommend. Examples include, but are not
limited to: making a determination of eligibility or coverage for insurance
benefits, reviewing services provided to you for medical necessity, providing
psychiatric and other mental health records, which may include psychiatric
and psychotherapy notes , to your insurer at the request of your
insurer, and undertaking utilization review activities. Generalized summaries
of psychiatric medication management, supportive therapy, and generalized
summaries of psychotherapy notes may be released unless specifically
prohibited by you . Obtaining
approval for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the hospital
admission. By signing the MBBH Patient Information, Consent and Authorization form
you will be giving us explicit permission to use your records in this manner,
until such time as you revoke this authorization in writing to as provided
below.
Healthcare
Operations: We may use or
disclose your protected health information in order to support the business
activities of our practice. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of medical
students, licensing, and conducting or arranging for other business activities.
For example,
we may also call you by name in the waiting room when your provider is ready to
see you. We may also use or disclose your protected health information to
contact you to remind you of your appointment. For example, we may call your contact phone number(s) and leave a
message, or email you at the email address you provide us, to remind you of the
time and date of your next appointment at MBBH.
If you send MBBH an email, you are authorizing MBBH to use email to
correspond with you using the Reply Address in that email.
We will
share your protected health information with third party “business associates”
that perform various activities (e.g., transcription and collection services)
for the practice. Whenever an arrangement between our office and a business
associate involves the use or disclosure of your PHI, we will have a written
contract that contains terms that will protect the privacy of your PHI.
Uses and Disclosures of Protected Health Information Based upon Your
Specific Written Authorization
Other uses
and disclosures of your protected health information will be made only with
your specific written authorization, unless otherwise permitted or required by
law as described below. You may revoke this authorization, at any time, in
writing, except to the extent that MBBH has taken an action in reliance on the
use or disclosure indicated in the authorization.
MBBH
is allowed to disclose PHI containing psychiatric and psychotherapy notes unless
specifically prohibited by you . However, you may not be entitled to
receive a copy of such notes under some conditions. Requests must be made on the MBBH
Request for Release of Psychotherapy Information & Authorization form. Generalized summaries of psychiatric
medication management supportive therapy and generalized summaries of
psychotherapy notes may be released as well, unless specifically prohibited
by you, as outlined in the Payment
paragraph above. If you are
being treated under a Worker Compensation claim PHI may be released as
appropriate. “Psychotherapy
Notes” may include Psychiatric and/or Psychotherapy notes and/or
Evaluations. Should you opt not to
disclose this information, it may result in loss of care.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
We may use
and disclose your protected health information in the following instances. You
have the opportunity to agree or object to the use or disclosure of
all or part of your protected health information. If you are not present or
able to agree or object to the use or disclosure of the protected health
information, then we may, using professional judgment, determine whether the
disclosure is in your best interest. In this case, only the protected health
information that is relevant to your health care will be disclosed.
Others Involved in
Your Healthcare: Unless we have specific permission from you, on an MBBH
Psychotherapy ROI, we are prohibited from disclosing any PHI in any form with
family members, relatives, or close friends who may be involved in your
care. The exception to this would be an
emergent situation as outlined below. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional judgment.
We may use or disclose protected health information to notify or assist in
notifying a family member, personal representative, or any other person that is
responsible for your care of your location, general condition, or death.
Finally, we may use or disclose your protected health information to an authorized
public or private entity to assist in disaster relief efforts and to coordinate
uses and disclosures to family or other individuals involved in your health
care.
Emergencies: We may use or
disclose your protected health information in an emergency treatment situation.
If this happens, we shall try to obtain your consent as soon as reasonably
possible after the delivery of treatment. If we are required by law to treat
you and we have attempted to obtain your consent but is unable to obtain your
consent, we may still use or disclose your protected health information to
treat you. We may use and disclose your protected health information if we
attempt to obtain consent from you but are unable to do so due to substantial
communication barriers and we determine, using professional judgment, that you
intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization, or Opportunity to Object
We may use
or disclose your protected health information to the extent that the use or
disclosure is required by law. The use or disclosure will be made in compliance
with the law and will be limited to the relevant requirements of the law. You
will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your
protected health information for public health activities and purposes to a
public health authority that is permitted by law to collect or receive the
information. The disclosure will be made for the purpose of controlling
disease, injury, or disability. We may
disclose your protected health information, if authorized by law, to a person
who may have been exposed to a communicable disease or may otherwise be at risk
of contracting or spreading the disease or condition.
Abuse or Neglect: We may disclose your
protected health information to a public health authority that is authorized by
law to receive reports of child abuse or neglect. In addition, we may disclose
your protected health information if we believe that you have been a victim of
abuse, neglect, or domestic violence to the governmental entity or agency
authorized to receive such information. In this case, the disclosure will be
made consistent with the requirements of applicable federal and state laws.
Legal Proceedings: We may disclose
protected health information in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative tribunal (to
the extent such disclosure is expressly authorized), in certain conditions in
response to Court Order.
Criminal Activity: Consistent with
applicable federal and state laws, we may disclose your protected health
information, if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to your health or safety, or the health
or safety of another person or the public.
Workers’
Compensation: Your protected health information may be disclosed by us as
authorized to comply with workers’ compensation laws and other similar
legally-established programs.
Required Uses and
Disclosures: Under the law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of Section 164.500 et. seq.
Section 2. Your Rights
Following is a statement of your rights with respect to your protected
health information and a brief description of how you may exercise these
rights.
You have the right
to inspect and copy your protected health information. This means you
obtain or request the release to others a copy of protected health information
about you that is contained in a designated record set for as long as we
maintain the protected health information. A “designated record set” contains
medical and billing records and any other records that we use for making
decisions about you. Requests must be made on the MBBH Request for Release of Information
& Authorization form. Other
formats may not be allowed. We may charge you or a third party for this
service, payable in advance.
Under
federal law, however, you may not necessarily have copies of the following
records; psychotherapy and psychiatric progress notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected health information that is subject to law
that prohibits access to protected health information. Depending on the
circumstances, a decision to deny access may be reviewed. Please contact our
Privacy Contact if you have questions about access to your PHI.
You have the right
to request a restriction of your protected health information. This means you may
request us in writing not to use or disclose any part of your protected health
information for the purposes of treatment, payment, or healthcare operations.
You may also request that any part of your protected health information not be
disclosed to family members or friends who may be involved in your care or for
notification purposes as described in this Notice of Information Practices .
MPG is not
required to agree to a restriction that you may request. If we believe it is in
your best interest to permit use and disclosure of your protected health
information, your protected health information will not be restricted. If we do
agree to the requested restriction, we may not use or disclose your protected
health information unless it is needed to provide emergency treatment. With
this in mind, please discuss any restriction you wish to request with us. Your
request must state the specific restriction requested and to whom you want the
restriction to apply. You may request restriction by completing the MPG Request for
Use/Restriction of PHI form and making an appointment with MBBH’s Privacy
Contact noted below.
You may have the
right to have MBBH amend your protected health information. This means you may request an amendment of protected health
information about you in a designated record set for as long as we maintain
this information. 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 prepare a rebuttal to your statement and
will provide you with a copy of any such rebuttal. Please contact our Privacy
Contact if you have questions about amending your medical record. You may request an amendment by completing the MBBH
Request for Amendment of PHI form and making an appointment with MBBH’s
Privacy Contact noted below.
You have the right
to receive an accounting of certain disclosures we have made of your protected
health information. This right applies to disclosures for purposes other than
treatment, payment, or healthcare operations as described in this Notice of
Information Practices. It excludes disclosures we may have made to you, to
family members or friends involved in your care, or for notification purposes.
You have the right to receive specific information regarding these disclosures
that occurred after April 14, 2003. You may request a shorter timeframe. The right
to receive this information is subject to certain exceptions, restrictions and
limitations as noted below. You may request an amendment by completing the MBBH
Request for Accounting of PHI Disclosure form and making an appointment
with MPG’s Privacy Contact noted below.
You
are entitled to an accounting of the use and disclosures of protected health
information for occurrences other than for treatment, payment, or health care
operations. MBBH is not required to
account disclosures for referring physicians, consults, or specialty procedures
that are a result of an indirect patient relationship by another provider. Also, disclosures for law enforcement purposes
or that are required by statutory law and that do not need an authorization are
not required to be accounted. The
accounting will also not include disclosures to the individual requesting the
accounting, for national security or intelligence purposes, to correctional
institutions, law enforcement officials, or that occurred prior to April 14,
2003.
MBBH
has sixty (60) days to comply with this request and must be granted a thirty
(30) day extension with a written explanation regarding the reason for the
delay. We must also provide the accounting
of PHI without charge for requests in any 12 month period. For more than one request in a 12 month
period, we may charge for printing or copying of PHI. Accountings will be mailed to the requestor
by regular U.S. Mail to the address on the MBBH
Request for Accounting of PHI Disclosure .
Section 3. Complaints
You may
complain to us or to the Secretary of Health and Human Services if you believe
your privacy rights have been violated by us. You may file a complaint with us
by notifying our Privacy Contact of your complaint. We will not retaliate
against you for filing a complaint.
You may
contact our Privacy Contact, Brenda Beck at 605-348-8000, ext. 212 for
further information about the complaint process.
Section 4. You are part of the MBBH Privacy Team
Who and what
you see at the Manlove Brain and Body Health clinic, as well as what you may
overhear while you are at the Clinic must “stay here.” Just as you would not want someone discussing
that you, your family member or friend, are a patient at the MBBH clinic,
neither should you tell others who you see receiving care.
You have the right to obtain a copy of
this Notice from us , upon request.
This notice was published and becomes effective on
April 14, 2003. Revised
09/01/2019
Version: 2019