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Notice of Privacy Practices: How You Can Exercise Your Rights To Access And Control Of Your Clinical Information

We want you to know that you have the following rights to access and control your clinical information. These rights are important because they will help you make sure that the clinical information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about the services you receive.

1. Right To Inspect And Copy Records

You have the right to inspect and obtain a copy of any of your clinical information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes service and billing records. To inspect or obtain a copy of your information, please submit your request in writing to the Director of the Division through which you receive services. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. The fee charged will be determined on a sliding scale basis but will not exceed 75ยข per page.

We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days if the information is located in our facility, and within 60 days if it is located off-site at another facility. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.

Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we will provide you with a summary of the information to which access is denied. We will also provide a written notice that explains our reasons for providing only a summary, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. The notice will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.

2. Right To Request Amendment of Records

If you believe that the clinical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. To request an amendment, please write to the Director of the Division through which you receive services. Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.

3. Right To An Accounting Of Disclosures

After April 14, 2003, you have a right to request an "accounting of disclosures" which is a list that contains certain information about how we have shared your information with others. An accounting list, however, will not include any information about:

  • Disclosures we made to you;
  • Disclosures we made pursuant to your authorization;
  • Disclosures we made for treatment, payment or health care operations;
  • Disclosures made to your friends and family involved in your care or payment for your care;
  • Disclosures made to federal officials for national security and intelligence activities;
  • Disclosures that were incidental to permissible uses and disclosures of your clinical information;
  • Disclosures for purposes of research, public health or our normal business operations of limited portions of your clinical information that do not directly identify you;
  • Disclosures made during the course of a review by a licensing and/or regulatory body;
  • Disclosures about inmates to correctional institutions or law enforcement officers; or
  • Disclosures made before April 14, 2003.

To request this accounting list, please write to the Director of the Division through which you receive services. Your request must state a time period within the past six years (but after April 14, 2003) for the disclosures you want us to include. You have a right to receive one accounting list within every 12 month period for free. However, we may charge you for the cost of providing any additional accounting list in that same 12 month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.

Ordinarily we will respond to your request for an accounting list within 60 days. If we need additional time to prepare the accounting list you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting list. In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.

4. Right To Request Additional Privacy Protections

You have the right to request that we further restrict the way we use and disclose your clinical information to treat your condition, collect payment for that treatment, or run our agency's normal business operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. To request restrictions, please write to the Director of the Division from which you receive services. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

5. Right To Request Confidential Communications

You have the right to request that we communicate with you about your treatment in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you by fax instead of by mail, or at work instead of at home. To request more confidential communications, please write to the Director of the Division from which you receive services. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your clinical care will be handled if we communicate with you through this alternative method or location.

6. Entities to Whom We Can Release Information Without Your Authorization

  • To government agencies or private insurance companies in order to obtain payment for services we provide to you;
  • To comply with a court order;
  • To appropriate persons who are able to avert a serious and imminent threat to the health or safety of you or another person;
  • To appropriate government authorities to locate a missing person or conduct a criminal investigation as permitted under Federal and State confidentiality laws (limited to identifying data only);
  • To other licensed agency emergency services as permitted under Federal and State confidentiality laws;
  • To an attorney representing you in an involuntary hospitalization or mediation proceeding. (We will not disclose clinical information about you to an attorney for any other reason without your authorization, unless we are ordered to do so by a court.)
  • To authorized government officials for the purpose of monitoring or evaluating the quality of care provided by the agency or its staff;
  • To qualified researchers when such research poses minimal risk to your privacy; and
  • To coroners and medical examiners to determine cause of death.
  • Emergency Or Public Need. We may use or disclose clinical information about you in an emergency or for important public needs.
  • As Required By Law. We may use or disclose your clinical information if we are required by law to do so, or if a court orders us to do so in a lawsuit or judicial proceeding. We also will notify you of these uses and disclosers if notice is required by law.
  • Victims Of Abuse, Neglect Or Domestic Violence. We may release clinical information about you to a public health authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we may report your information to government officials if we reasonably believe that you have been a victim of abuse, neglect or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.
  • National Security And Intelligence Activities or Protective Services. We may disclose clinical information about you to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.
  • We may use or disclose clinical information about you if we have removed any information that might reveal who you are.

Signature

By signing below, I acknowledge that I have been provided a copy of the Liberty Resources, Inc. Notice of Privacy Practices and the statement "How You Can Exercise Your Rights to Access And Control Of Your Clinical Information" and have therefore been advised of how clinical information about me may be used and disclosed by Liberty Resources, Inc. and how I may obtain access to this information.

Signature of Consumer or Personal Representative:

Print Name of Consumer or Personal Representative:

Date:

Description of Personal Representative's Authority:

Signature of Witness (if necessary):

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