Notice Effective Date: 4/1/2016
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.
This notice is to explain the rules around the privacy of your own medical/health records and our legal duties on how to protect the privacy of your medical/health records that we create or receive. Generally, we are required by law to ensure that medical/health information that identifies you is kept private. We are required by law to follow the terms of the notice that are the most current.
This notice will explain:
How we may use and disclose your medical/health information
Our obligations related to the use and disclosure of your medical/health information
Your rights related to any medical/health information that we have about you
Inform you about the Omnibus Rule, 9/23/2013, changes that have modified HIPAA
This notice applies to the medical/health records that are generated in or by this agency. The terms “medical” and “medical/health” in this Notice means information about your physical or mental condition which make you eligible for our services, or which arise while we are serving you. For example, this may include psychological tests, psychiatric assessments or medical or social assessments.
We may obtain, but we are not required to, your consent for the use or disclosure of your protected health information for treatment, payment or health care operations. We are required to obtain your authorization for the use or disclosure of your information for other specific purposes or reasons. We have listed some of the types of uses or disclosures below. Not every possible use or disclosure is covered, but all of the ways that we are allowed to use and disclose information will fall into one of the categories.
If you have any questions about the content of this Notice of Privacy Practices, or if you need to contact someone at the agency about any of the information contained in this Notice of Privacy Practices, the contact person is the Privacy Officer or designee:
HIPAA Privacy Officer, (636) 321-0114
HIPAA Official Designee, (636) 931-2700 Ext 1047
In addition to agency departments, employees, staff and other agency personnel, the following people will also follow the practices described in this Notice of Privacy Practices:
Any health care professional who is authorized to enter information in your medical/health record
Any occasional volunteer that we allow to help you while you are in the agency
All providers that the Department of Mental Health contracts with to provide services to our consumer (which defines what we mean by “organized health care arrangement”)
The class of entities that make up the organized health care arrangement are:
The Missouri Department of Mental Health (DMH)
DMH Division of Comprehensive Psychiatric Services (CPS)
DMH Divisions of Alcohol and Drug Abuse (ADA) and Mental Retardation - Developmental Disabilities
Behavior Health Response (BHR)
MO HealthNet Division
Safe Haven Partner Agencies
Missouri Protection and Advocacy Services
These other individuals or providers are considered part of Comtrea’s “Organized Health Care Arrangement” and should follow the terms of this Notice of Privacy Practices.
In addition, individuals and providers who are in the Organized Health Care Arrangement may share medical information with each other about Comtrea consumers they serve in common for the purpose of treatment, payment or health care operations as those terms are described later in this Notice of Privacy Practices. These other individuals and providers who are in the Organized Health Care Arrangement are included throughout this document whenever we use the term “agency.”
Omnibus Rule modifications to the HIPAA Rule include:
Your authorization is required for uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI
Your authorization is required for most uses and disclosures of psychotherapy notes
Any other uses and disclosures not described in this NPP will be made only with authorization from the individual to whom the PHI relates
You have the right to opt out of receiving such communications regarding Fundraising communications to raise funds for agency programs
You have the right, if you pay out-of-pocket in full for a healthcare item or service, to restrict disclosures of PHI to your health plan
You will be notified following a breach of unsecured PHI
How We May Use And Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical/health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Use and Disclosure of Medical Information
We can use or disclose medical information about you regarding your treatment, payment for services, or for agency operations, and we will make a good faith effort to have you acknowledge your copy of the Notice of Privacy Practices.
Treatment - We may use medical information about you to provide you with treatment or services. We may disclose medical information about you to qualified mental health professionals, or QMHPs; qualified mental retardation professionals or QMRPs; or to qualified counselors; or, technicians, interns/students, or other agency personnel, occasional volunteers or student/interns who are involved in providing services for you at the agency, or interpreters needed in order to make your treatment accessible to you. For example, your treatment team members will internally discuss your medical/health information in order to develop and carry out a plan for your services. Different departments of the agency also may share medical/health information about you in order to coordinate the different things you need, such as prescriptions, medical tests, special dietary needs, respite care, personal assistance, day programs, etc. We also may disclose medical/health information about you to people outside the agency who may be involved in your medical care after you leave the agency, such as our organized health care arrangement members or others we use to provide services that are part of your care, but only the minimum necessary amount of information will be used or disclosed to carry this out.
Payment - We may use and disclose medical/health information about you so that the treatment and services you receive at the agency may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to provide your insurance plan information about psychiatric treatment or rehabilitation services you received at the agency so your insurance plan, or any applicable Medicaid or Medicare funds, will pay us for the services. We may also tell your insurance plan or other payer about a service you are going to receive in order to obtain prior approval or to determine whether the service is covered. In addition, in order to correctly determine your ability to pay for services, we may disclose your information to the Social Security Administration, the Division of Employment Security, or the Department of Social Services.
Health Care Operations - We may use and disclose medical/health information about you for agency operations. These uses and disclosures are necessary to run the agency and make sure that all of our consumers receive quality care. For example, we may use medical/health information for quality improvement to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many agency consumers to decide what additional services the agency should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, intern/students, and other agency personnel as listed above for review and learning purposes. We may also combine the medical/health information we have with medical/health information from other agencies to compare how we are doing and see where we can make improvements in the care and services we offer. It may also be necessary to obtain or exchange your information with Elementary and Secondary Schools, Missouri Department of Social Services (Family Support Division and Children’s Division), Vocational Rehabilitation, the Office of State Courts Administrator, or other Missouri state agencies or interagency initiatives, such as the System of Care initiative. Or, we may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning the identity of specific consumers. This may be in the form of providing information to our regional advisory councils or state advisory councils, planning councils or the Comtrea Corporation Board and Jefferson County Community Mental Health Fund Board.
Uses and Disclosures of Medical/Health Information That Do Not Require Your Consent or Authorization:
We can use or disclose health information about you without your consent or authorization when
There is an emergency or when we are required by law to treat you
We are required by law to use or disclose certain information,
There are substantial communication barriers to obtaining consent from you
We can also use or disclose health information about you without your consent or authorization for:
Appointment Reminders - We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or services at the agency.
Treatment Alternatives and Health-Related Benefits and Services - We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services that may be of interest to you.
Individuals Involved in Disaster Relief - Should a disaster occur, we may disclose medical information about you to any agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research - Under certain circumstances, medical information may be disclosed for research purposes when a waiver of authorization has been approved by an Institutional Review Board or Privacy Committee. Before we use or disclose medical/health information for research, the project will have been approved through this research approval process.
As Required By Law - We will disclose medical/health information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety - We may use and disclose medical/health information about you when necessary to prevent a serious threat to the health and safety of you, the public, or any other person. However, any such disclosure would only be to someone able to help prevent the threat.
Organ and Tissue Donation - If you are an organ donor, we may release medical/health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans - If you are a member of the armed forces, we may release medical/health information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation - When disclosure is necessary to comply with Workers’ Compensation laws or purposes, we may release medical/health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks - We may disclose medical/health information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a consumer has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities - We may disclose medical/health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. In addition, we may use personal information to study health care without revealing who you are in order to provide better services.
Lawsuits and Disputes - If you are involved in a lawsuit or a dispute, we may disclose medical/health information about you in response to a court or administrative order.
Law Enforcement - We may release medical/health information if asked to do so by a law enforcement official; however, if the material is protected by 42 CFR Part 2 (a federal law protecting the confidentiality of drug and alcohol abuse treatment records), a court order is required. We may also release limited medical/health information to law enforcement in the following situations: (1) about a consumer who may be a victim of a crime if, under certain limited circumstances, we are unable to obtain the consumer’s agreement; (2) about a death we believe may be the result of criminal conduct; (3) about criminal conduct at the agency; (4) about a consumer where a consumer commits or threatens to commit a crime on the premises or against program staff (in which case we may release the consumer’s name, address, and last known whereabouts); (5) in emergency circumstances, to report a crime, the location of the crime or victims, and the identity, description and/or location of the person who committed the crime; and (6) when the consumer is an inmate and we are required to share with law enforcement by Missouri statute.
Coroners, Medical Examiners and Funeral Directors - We may release medical/health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical/health information about consumers of the agency to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities - We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others - We may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President and other authorized persons or foreign heads of state.
Inmates - If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical/health information about you to the correctional institution or law enforcement official if the release is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Emergency or Disaster Events - In the interest of public safety and planning for community needs in an emergency or disaster event, we may disclose general information about you to emergency managers, fire, law enforcement, public health authorities, emergency medical services such as ambulance districts, utilities, and other public works officials regarding:
The numbers and locations of DMH clients in community and state-operated settings
Any special needs identified in these settings for purposes of rescue such as sensory, cognitive and mobility impairments
Special assistance and supports needed to effectively meet these needs such as communication devices, specialized equipment for evacuation, etc
Necessary information to order necessary treatment or prophylaxis supplies and medications in the event of a public health emergency
Emergency notification contacts to expedite contact with families, legal guardians or representatives or others regarding need for evacuation or emergency medical care
Any special needs that justify prioritization of utility restoration such as but not limited to dependence on respirator or other medical equipment, phone for emergency contact, etc.
Any other information that is deemed necessary to protect the health, safety and well-being of DMH consumers.
Your Rights Regarding Medical/Health Information About You
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy (Request for Consumer Access of Protected Health Information FMTRT0203). You have the right to inspect and copy your medical/health information with the exception of psychotherapy notes and information compiled in anticipation of litigation.
In addition Comtrea will not release any information considered to be a secondary release such as records from another physician, hospital, or other healthcare provider outside of Comtrea. To inspect and copy your medical/health information, you must submit your request in writing to this agency’s Privacy Officer or designee. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical/health information because of a threat or harm issue, you may request that the denial be reviewed. Another licensed health care professional chosen by the agency will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Request an Amendment (Request for Amendment FMTRT0204) If you feel that medical/health 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 by or for the agency. Requests for an amendment must be made in writing and submitted to the Privacy Officer or designee. You must provide a reason to support your request for an amendment. We may deny your request if it is not in writing or if it does not include a reason supporting the request. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment:
Is not part of the medical information kept by or for the agency
Is not part of the information which you would be permitted to inspect and copy
Is accurate and complete
Right to an Accounting of Disclosures (Request for Accounting of Disclosure of Consumer Protected Health Information FMTRT0202) You have the right to request an "accounting of disclosures", a list of the disclosures made by the agency of your medical/health information. To request an accounting of disclosures, you must submit your request in writing to this agency’s Privacy Officer or designee. Your request must state a time period which may not go back more than six years and cannot include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists in a twelve-month period, we may charge you for the cost of providing the list. We will notify you what that cost will be and give you an opportunity to withdraw or modify your request before you are charged. There are some disclosures that we do not have to track. For example, when you give us an authorization to disclose some information, we do not have to track that disclosure.
Right to Request Restrictions (Request to Restrict Protected Health Information FMTRT0201). You have the right to request a restriction or limitation on the medical/health information we use or disclose about you for treatment, payment or health care operations. For example, you could ask that we not use or disclose information about your family history to a particular community provider. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restrictions on the use or disclosure of your medical/health information for treatment, payment or health care operations, you must make your request in writing to the agency’s Privacy Officer or designee. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).
Right to Request Confidential Communications (Authorization to Disclose/Receive Client Medical/Health Information FMTRT0039). You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the agency’s Privacy Officer or designee. Your request must specify how or where you wish to be contacted. We will not ask you the reason for your request and will accommodate all reasonable requests.
Right to a Paper Copy of This Notice You have the right to a paper copy of this notice even if you have agreed to receive the notice electronically. You may ask us to give you a copy of this notice at any time by contacting the agency’s Privacy Officer or designee. You may also obtain a copy of this notice at our website, http://www.comtrea.org If you wish to exercise any of these rights, please contact: HIPAA Privacy Officer, (636) 321-0114 or HIPAA Official Designee, (636) 931-2700 Ext 1047
Changes To This Notice
We reserve the right to change this notice. We may make the revised notice effective for medical/health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the agency. 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 or apply for services to the agency for treatment or services, we will offer you a copy of the current notice in effect. If you want to request any revised Notice of Privacy Practice, you may access it at our website, http://www.comtrea.org
To file a complaint with the agency, contact Privacy Officer or Designee, at the following address and telephone number.
HIPAA Privacy Officer, (636) 321-0114
HIPAA Official Designee, (636) 931-2700 Ext 1047
All complaints must be submitted in writing (Privacy Complaint Form, FMMSC0071). You will not be penalized for filing a complaint. Other resources are the Secretary of the Department of Health and Human Services, 877.696.6775, 200 Independence Ave. S.W., Washington, DC, 20201 or the Office of Civil Rights, 866-OCR-PRIV (866.627.7748), 886.788.4989 TTY.
Other Uses Or Disclosures Of Medical/Health Information.
Uses or disclosures not covered in this Notice of Privacy Practices will not be made without your written authorization. If you provide us written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as it is in writing. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization.
Disclaimer – Comtrea strives to protect every client’s privacy however problems can arise when family or friends are employed by Comtrea and we are not aware of those relationships. If, as a client, you would like to make us aware of any relationships you may have with Comtrea staff, please call the HIPAA Privacy Officer or the HIPAA Official Designee, and we will take appropriate actions to secure your recor