MIRROR, INC. NOTICE OF USE OF PRIVATE HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Mirror understands that information we collect about you and your health is personal. Keeping your health information private is one of our most important responsibilities. We are committed to protecting your health information and following all laws regarding the use of your health information. The following is a notice of our legal duties and privacy practices with respect to your health information as it relates to the pertinent sections contained in Title 45 of the Code of Federal Regulations (CFR) and the “Health Insurance Portability and Accountability Act” or HIPAA. If you have questions about any part of this notice or if you want more information about the privacy practices at Mirror, please contact the Facility Coordinator for the Mirror program you are enrolled in, or the Mirror Compliance Officer, John F. Gilbert, Executive Vice President (Human Resources/Compliance).
A. How Mirror May Use or Disclose Your Health Information:
The following categories describe the ways Mirror may use and disclose your health information, as part of our normal operations to assist you, without asking you for permission. For each category of uses and disclosures, we will explain what we mean and present some examples. In each category we will only disclose the minimum amount of information needed to accomplish the task. Not every use or disclosure in a category will be listed. However, the ways we are permitted to use and disclose information will fall within one of the categories.
1. Treatment: We may use or disclose health information about you to provide the necessary treatment for you. For example, if you are a client of one of the Mirror treatment programs, we may use medical (health) information about you to provide you with treatment or services. We may disclose health information about you to qualified mental health professionals; qualified medical professionals; qualified counselors or other social services professionals. It is worth noting that programs offering alcohol and drug treatment services also fall under the Federal Confidentiality Regulations (also known as “Confidentiality of Alcohol and Drug Abuse Patient Records Title-42 CFR Chapter One Part 2). This legislation is fairly detailed and wide sweeping in nature. The law has been on the books, so to speak, for over a quarter of a century. Under this law, release of information concerning clients enrolled in addiction treatment services is generally limited to disclosures only if permitted in writing by the client. Some exceptions to this apply but will not be discussed in this document. Your treatment team members will internally discuss your health information in order to develop and carry out a plan for your services. Different departments of the agency may share health or other information about you in order to coordinate the different things you need, such as prescriptions, medical tests, special dietary needs, personal assistance, etc. We also may disclose information with people outside the agency who may be involved in your medical (health) care, but only the minimum necessary amount of information will be used or disclosed to carry this out.
2. Payment Functions: We may use or disclose health information about you to determine eligibility for plan benefits, obtain premiums, facilitate payment for the treatment and services received from providers, determine program responsibilities for benefits, and to coordinate program benefits. For example, payment functions may include reviewing the medical necessity for health care services, reviewing a plan of care for payment to one of the Mirror community-based partners such as a state mental hospital, a Community Mental Health Center, a Regional Alcohol and Drug Abuse Treatment or Assessment Center just to mention a few. We may also use or disclose health information to facilitate proper payment for treatment such as providing your Medicaid or other health insurance coverage identification number to a health care provider, a pharmacy, or other health providers who have agreed to provide services for our clients.
3. Health Care Operations: We may use or disclose health information about you to carry out necessary program related activities. Such activities may include activities related to plan coverage; conducting quality assessment and improvement activities; conducting or arranging for medical or program reviews, legal services, audit services, and fraud and abuse detection programs; business planning, management and general administration; case management and care coordination; accreditation, certification, licensing, or credentialing activities.
4. Required by Law: As required by law, we may use and disclose your health information. For example, we may disclose health information when required by a court order in a litigation proceeding such as a civil or criminal proceeding, a malpractice action, a child custody hearing, etc. As mentioned in item 1 above the Federal Confidentiality Law also specifies when treatment providers are required to release information to the courts. Again this law is detailed and specific in nature and the court order must meet rigorous criteria set forth in 42 CFR 1-Part 2.
5. Public Health: As required by law, we may use and disclose your health information to public health authorities for purposes related to: preventing or controlling disease; injury or disability; reporting child abuse or neglect; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
6. Disclosures about Victims of Abuse, Neglect or Domestic Violence: We may disclose protected health information about an individual who we reasonably believe is a victim of abuse, neglect, or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect or domestic violence.
7. Health Oversight Activities: We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings related to oversight of the Mirror programs. Examples would be sharing health information with the Kansas Department of Social and Rehabilitation Services, Division of Health Care Policy, Mental Health, Addiction and Prevention Services for their licensure activities involving free standing addiction focused facilities, or the Kansas Department of Corrections, Administrative Office of the United States Courts, United States Probation Office and the United States Department of Justice, Federal Bureau of Prisons for their audit and/or compliance activities involving contracting agencies.
8. Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding. Please see items 1 and 4 above.
9. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, or complying with court order or subpoena and other law enforcement purposes.
10. Coroners, Medical Examiners and Funeral Directors: We may disclose your health information to coroners, medical examiners and funeral directors, if, for example, it is necessary to identify a deceased person or determine the cause of death.
11. Organ and Tissue Donation: We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues, as necessary.
12. Public Safety: We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of you, a particular person or the general public. Any disclosure, however, would only be to someone able to prevent the threat.
13. National Security: We may release health information to authorized federal officials for intelligence, counter intelligence, and other national security activities authorized by law.
14. Protection Services for the President and Others: We may disclose your health information to authorized federal officials so they may provide protection to the President of the United States, other authorized persons or foreign heads of state or to conduct special investigations.
15. Worker’s Compensation: We may disclose your health information as necessary to comply with Worker’s Compensation or similar laws.
16. Appointment Reminders: We may disclose your health information to contact you with appointment reminders for treatment or services provided by Mirror, Inc.
17. Research Activities: We may disclose health information about you for research purposes. However, if the research project involves specific confidential information about you, we will seek your specific written permission.
18. Inmates (parolees, probationers, etc…): If you are an inmate of a federal or state correctional institution or under the custody or supervision of a law enforcement official then we may release information about you that would be necessary (1) for the institution or law enforcement official to provide you with or make referral for proper health care; (2) to protect your health and safety or to protect the health and safety of others; or (3) for the safety and security of the correctional institution or Mirror programs.
B. When Mirror May Not Use or Disclose Your Health Information.
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time to the Mirror Facility Coordinator for the Mirror program you are enrolled in or the Mirror Compliance Officer. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission. Please understand that criminal justice referrals are unable to revoke authorization(s) to certain parties.
C. Statement of Your Health Information Rights
1. Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information. Mirror is not required to agree to the restrictions you request. If you would like to make a request for restrictions, you must submit your request in writing to the Facility Coordinator for the Mirror program you are enrolled in.
2. Right to Request Confidential Communications: You have the right to receive your health information through a reasonable alternative means or at an alternative location. To request confidential communications, you must submit your request in writing to the Facility Coordinator for the Mirror program you are enrolled in.
3. Right to Inspect and Copy: You have the right to inspect and copy health information about you that may be used to make decisions about your treatment or benefits, with the exception of counseling notes, treatment plan evaluations, discharge summaries, alcohol/drug assessments, or information gathered for and used in legal or administrative proceedings. To inspect and copy such information, you must submit your request in writing to the Mirror Compliance Officer, indicated on page one of this document. If you request a copy of the information, we require that you prepay a reasonable fee to cover expenses associated with your request. Typically, we would charge $1.00 per copied page and $25.00 per hour of staff time to locate and copy your health information (regardless of the number of pages involved there will be a minimum charge of $25.00 assessed to you).
4. Right to Request Amendment: You have the right to request that Mirror amend your health information that you believe is incorrect or incomplete. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must make your request in writing to the Mirror Compliance Officer listed on the first page of this document.
5. Right to an Accounting of Disclosures: You have the right to receive a list of “accounting of disclosures” of your health information made by us, except that we do not have to account for disclosures made for purposes described in Section A 1-3, of this document, disclosures authorized by you or disclosures made to you. To request this list of disclosures you must submit your request in writing to the Mirror Compliance Officer listed on the first page of this document. A minimum of $25.00 will be assessed to you for this request since a brief letter will need to be drafted and sent to you at the location designated by you. Again, we will require that you pre-pay for this service.
6. Right to Paper Copy: You have the right to receive a paper copy of this Notice of Privacy Practices at any time. To obtain a paper copy of this Notice, send your written request to the Facility Coordinator for the Mirror program you are enrolled in, or the Mirror Privacy Officer, the Mirror Executive Vice President (Human Resources/Compliance). You may also obtain a printable copy of this Notice at our website, www.mirrorinc.org
D. Changes to the Notice of Privacy Practices:
Mirror reserves the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice provisions effective for all health information that it maintains. We will promptly revise our Notice and distribute it to you whenever we make material changes to the Notice. Until such time, Mirror is required by law to comply with the current version of this Notice.
E. Complaints:
If you believe your privacy rights have been violated, you may take the following actions:
File a written complaint with Mirror by contacting the Mirror Compliance Officer, John F. Gilbert at the Mirror Corporate Office P. O. Box 711, Newton, Kansas 67114 or by filing a written complaint with the United States Department of Health & Human Services, (Region 7 Office of Civil Rights), Bolling Federal Building, 601 East 12th Street, Kansas City, MO 64106
You will not be retaliated against for filing a complaint. Your health care services and/or benefits with Mirror will not be affected in any way.
The Mirror Board of Directors at their regularly scheduled meeting on November 18, 2004 approved the Mirror “HIPAA-Privacy Notice”. This Notice of Privacy Practice shall be become effective for agency use on the above date as well.