Privacy Practices

 

Deerfield Behavioral Health, Inc.
2520 Hampton Road, Erie, PA 16502

Deerfield Center for Addictions Treatment
115 West Spring Street, Titusville, PA 16354
111 Bridge Street, Tionesta, PA 16353
125 Chestnut Street, Marienville, PA 16239
514 West Third Avenue, Warren, PA 16365

Deerfield Behavioral Health of Warren, LLC
514 West Third Avenue, Warren, PA 16365
28 East Columbus Avenue, Corry, PA 16407
23 Kennedy Street, Suite 302, Bradford, PA 16701

Deerfield Dual Diagnosis, LP
2610 German Street, Erie, PA 16504

(ALL ENTITES ABOVE ARE AFFILIATED FOR PURPOSES OF THESE PRIVACY PRACTICES)

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.

If you have any questions about this Notice please contact our Privacy Officer at (814) 456-2457

This Notice of Privacy 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. "Protected health information" is information about you, including demographic information, that may identify you and 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 Privacy Practices. We reserved the right to change the terms of this notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at

http://www.dbhn.com/phinotice.html

, or calling the office and requesting a revised copy be mailed or by asking for one at the time of your next appointment.



1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent

You will be asked by Deerfield staff to sign a consent to treatment form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing a consent to treatment form, your clinician may use or disclose your protected health information as described in this Section 1, without further authorization. Your protected health information may be used and disclosed by your clinician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of this facility.

 

Following are examples of the types of uses and disclosures of your protected health care information that Deerfield is permitted to make once you have signed our consent 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 will 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 authorization to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to an inpatient facility that provides care to you. We will also disclose protected health information to other clinicians 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 a clinician to whom you have been referred to ensure that the clinician has the necessary information to diagnose or treat you.

 

In addition, we may disclose your protected health information from time-to-time to another clinician or health care provider (e.g., a specialist or laboratory) actively engaged in treating you or to whom you may be referred or at the request of your clinician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your clinician.

 

NOTE: If you are being treated for a drug or alcohol program, your specific authorization would be needed to disclose information to other treatment providers.



Payment:

Your protected health information will be used, as needed, 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 for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, 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.



Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of Deerfield. These activities include, but are not limited to, quality assessment activities, employee review activities, training of clinicians, licensing, and conducting or arranging for other business activities.

 

For example, we may disclose your protected health information to graduate or intern students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your clinician. We may also call you by name in the waiting room when your clinician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

 

We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the facility. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

 

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about our facility and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.

 

We may use or disclose your demographic information and the dates that you received treatment from your clinician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materials not be sent to you.



Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your 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 your clinician or Deerfield has taken an action in reliance on the use or disclosure indicated in the authorization.



Other Permitted and Required Uses and Disclosures That May Be Made With 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 consistent with state and federal regulations, whether the disclosure is in your best interest and. In this case, only the protected health information that is relevant to your health care will be disclosed.



Others Involved in Your Healthcare:

With your authorization, we may disclose to a member of your family, a relative, a close friend or any other person included in your treatment, your protected health information that directly relates to your healthcare services. 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, if the condition is of an emergent nature. 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 legally 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.



Communication Barriers:

We may use and disclose your protected health information if your clinician or another Deerfield clinician attempts to obtain consent from you but is unable to do so due to substantial communication barriers or physical limitations, and the clinician determines, 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 in the following situations without your consent or authorization. These situations include:



Emergencies:

We may use or disclose your protected health information in an emergency treatment situation. If this happens, your clinician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your clinician, physician or another clinician at our facilities is required by law to treat you and has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.



Required By Law:

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 also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.



Drug and Alcohol Abuse Patients:

If you are being treated for a drug and/or alcohol abuse problem, your records may be released without your authorization only upon a court order where good cause has been show or for the purpose of assisting in emergency medical treatment where your life is in immediate jeopardy.



Communicable Diseases:

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.



HIV Disclosure:

Our physician may disclose confidential HIV-related information if all of the following conditions are met: (1) The disclosure is made to a known contact of the subject. (2) The physician reasonably believes disclosure is medically appropriate, and there is a significant risk of future infection to the contact. (3) The physician has counseled the subject regarding the need to notify the contact, and the physician reasonably believes the subject will not inform the contact or abstain from sexual or needle-sharing behavior which poses a significant risk of infection to the contact. (4) The physician has informed the subject of his intent to make such disclosure. When making such disclosure to a contact, the physician shall not disclose the identity of the subject or any other contact. Disclosure shall be made in person except where circumstances reasonably prevent doing so. A physician shall have no duty to identify, locate or notify any contact, and no cause of action shall arise for nondisclosure or for disclosure in conformity with this section.



Health Oversight:

We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.



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.

For example, your clinician or another person who in the course of their employment, occupation or practice of their profession, comes into contact with children and your clinician has reasonable cause to suspect that on the basis of their medical, professional or other training and experience, that a child coming before them in their professional or official capacity is an abused child, is required to report sufficient information to permit the Pennsylvania Department of Welfare, child protective services for investigation. What this means for you is that information shared with your clinician concerning the abuse of a child is not protected health information and may create the legal obligation of your clinician to report this information for investigation.

In addition, we may disclose your protected health information to the governmental entity or agency authorized to receive such information if you are over 60 years of age and we believe you are the victim of abuse or neglect. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

If you have questions about specific information you intend to share concerning this, you should discuss your clinician's duty to report prior to disclosure.

Minors Receiving Services:

Except as otherwise indicated herein, protected health information of patients over the age of 14 will not be disclosed to a parent, guardian or other person without the authorization of the patient except in cases to obtain the consent of the parent or guardian regarding treatment or as necessary to prevent serious risk of bodily harm or death of the minor. There may be exceptions to disclosure of PHI where a parent has authorized treatment for the minor and for purposes of consent for treatment of the minor.



Food and Drug Administration:

We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.



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 or required), in certain conditions in response to a subpoena, discovery request or other lawful process. We may disclose protected health information requested by any attorney who is retained or appointed to represent your legal interests.



Law Enforcement:

We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of Deerfield, and (6) medical emergency (not on Deerfield's premises) and it is likely that a crime has occurred.



Coroners, Funeral Directors, and Organ Donation:

We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.



Research:

We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.



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 the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Your protected health information if we have a reasonable basis to believe that you may have committed or conspired with another to commit a crime against Deerfield, its employees, contractors, or another patient at Deerfield. In this instance only protected health information believed to be relevant to the offense will be disclosed.



Military Activity and National Security:

When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.



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.



Inmates:

We may use or disclose your protected health information if you are an inmate of a correctional facility and your clinician created or received your protected health information in the course of providing care to you.



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.



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 may inspect and obtain 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 your clinician and Deerfield use for making decisions about you.

 

Under federal law, however, you may not inspect or copy the following records; psychotherapy 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 reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.



You have the right to request a restriction of your protected health information.

This means you may ask us 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 Privacy Practices.

Your request must state the specific restriction requested and to whom you want the restriction to apply.

 

We are not required to agree to a restriction that you may request unless otherwise required by law. If we believe it is in your best interest to permit the use and disclosure of your protected health information, your protected health information, it will not be restricted. If we agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your clinician. You may request a restriction by

contacting your clinician and informing them of your requested restriction.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.



You may have the right to have your clinician 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 to determine if you have questions about amending your medical record.



You have the right to receive an accounting of certain disclosures we have made, if any, 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 Privacy Practices. It excludes disclosures we may have made to you, or upon your request, for a facility directory, 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 occur after April 14, 2003 and for a period of up to six (6) years prior to the date of the request. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. We may charge a reasonable fee for a requested accountings in excess of two per twelve (12) month period which must be paid prior to acting on your request.



You have the right to obtain a paper copy of this notice from us

, upon request, even if you have agreed to accept this notice electronically.



Drug and Alcohol Abuse Information:

The confidentiality of alcohol and drug abuse patient records maintained by a program is protected by federal and state law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser Unless: (1) the patient consents in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with government regulations. Federal law and regulation

does not

and state law and regulation

may not

protect information about suspected child abuse or neglect from being reported under State law to appropriate state or local authorities. (42 U.S.C. 290dd-3, ee-3 and 42 CFR Part 2 and 71 P.S. § 1690.108). State regulations

limit

and federal regulations pertaining to drug and alcohol abuse clients

prohibit

, further disclosure of this information without express written consent of the person to whom it pertains, or as otherwise permitted by applicable regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. State and federal law restricts the use of this information to criminally investigate or prosecute any alcohol or drug abuse patient. (42 U.S.C. 290dd-3, ee-3 and 42 CFR Part 2). Your records may be released without your authorization only upon a court order where good cause has been show or for the purpose of assisting in emergency medical treatment where your life is in immediate jeopardy.



HIV Information:

If protected health information pertaining to HIV has been disclosed, Pennsylvania law prohibits the recipient from making any further disclosure of the information unless expressly permitted by your written consent or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose. (35 P.S. § 7601 et. seq.)



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 Officer at (814) 456-2457 or 2520 Hampton Road, Erie, PA 16502

for further information about the complaint process.

 

This notice was originally published and became effective on

April 14, 2003.

IF YOU HAVE RECEIVED THIS NOTICE OF PRIVACY PRACTICES ELECTRONICALLY, YOU MAY OBTAIN A PAPER COPY BY REQUEST AT THE OFFICE WHERE YOU RECEIVE SERVICES OR BY WRITING TO THE PRIVACY OFFICER LISTED ABOVE.

I acknowledge by my signature below, I have had an opportunity to receive or review a copy of the Deerfield's Privacy Notice and Patient Rights concerning protected health information.



_______________________________________________________
Patient/Client/Authorized Representative Signature

Date _________________

In the event a good faith effort has failed to obtain the acknowledgment of the patient/client, the reason therefore:
_______________________________________________________
_______________________________________________________


_______________________________________________________
Signature of Person Attempting To Obtain Above Signature

Date _________________