THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE REVIEW CAREFULLY.
The Circle of Care Consultants, Inc. (CCC) is committed to protecting the privacy and confidentiality of your personal and mental health information (PMHI). We are also mandated by federal and state law to assure that this protection occurs. The following notice outlines our privacy practices, legal duties and your rights concerning your PMHI. We are required by law to provide you with a copy of this notice. We must follow the terms of this notice which takes effect on April 14, 2003. Amendments to this notice may be made in writing by CCC as laws and or policies change.
CCC keeps medical records for each client that contracts our services for a period of seven (7) years after the commencement of services. Medical Records consist of a client’s PMHI and may include but are not limited to name, demographic information, referral information, assessments, evaluations, progress notes, treatment plan, medical and medication protocols, continuing care plan and financial/payment information. These records are necessary to provide you with the best interdisciplinary care, continuing care and are required by state licensing mandates.
HOW WE MAY USE AND DISCLOSE YOUR MENTAL HEALTH INFORMATION
Treatment: Your personal and mental health information (PMHI) may be disclosed to any The Circle of Care Consultants, Inc. staff member as needed to provide you with the best and most comprehensive services possible. Any and all personal or mental health information will only be disclosed to non-CCC related staff when CCC has obtained the express written consent of the client, except when required by law.
Payment: There may be instances when payment for treatment services will require disclosure of your PMHI. This is most common when payment is made by a third party such as an insurance company, workman’s compensation, another family member or your personal financial officer. Your PMHI will only be disclosed with your express written permission. It is important to know however that your refusal to give such permission may lead to non payment by that third party as without your written consent/authorization, we will be unable to discuss payment for your treatment services with any third party.
Healthcare Operations: The Circle of Care Consultants, Inc. may use and/or disclose your PMHI for healthcare operations such as audits by The Department of Mental Health, licensing issues, quality assurance, trainings, accreditation, certification and credentialing activities.
Teaching/Training/Supervision: We may disclose personal information regarding CCC clients in the context of teaching, trainings and the supervision of other members in the mental health field. Information will be disclosed only when the anonymity of the client can be guaranteed.
Your Authorization: Although your medical record is the physical property of CCC you have the right to review and receive a copy of your medical record. A written consent/authorization signed by the CCC client for such medical records must be obtained prior to the copying and or delivery of those records to that client. You may also request that your PMHI be disclosed to any person or agency that you choose for any purpose. You must provide a written consent/authorization for that information to be disclosed even when such a request is made by you. Such consent is valid for one year from the date originally signed. You have the right to revoke any consent/authorization at any time.
Disclosure to Family and Friends: Only the PMHI that you have specified will be disclosed and only to those that you have provided written consent/authorization for. In the event of your incapacity or under emergency circumstances, we will disclose your PMHI to that person you had previously designated as your “Emergency Contact Person(s)”. We will use our professional judgment to disclose reasonable information on an “as needed” basis.
As required by Law: We may use or disclose your PMHI when we are required by law. The Circle of Care Consultants, Inc. staff are mental health workers and are Mandate Reporters. This law requires us to report to the appropriate authorities if we reasonably believe that you or another human being may be the victim or offender of abuse, neglect, exploitation, domestic violence or other violent crimes. We may disclose your PMHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
The State of Florida defines the following terms as:
YOUR RIGHTS UNDER THE FEDERAL PRIVACY STANDARD
To request that The Circle of Care Consultants, Inc. place additional restrictions on certain uses and disclosures of your information: We are not required by law to agree with your request however, whenever possible as to not cause undue hardship to the flow of business of CCC we will honor such requests.
To obtain a copy of this notice of The Circle of Care Consultants, Inc.'s, Privacy Practices upon request: All CCC clients are given a copy of this notice upon contract and are asked to sign that copy to acknowledge they have seen it. Further, clients are given their own copy to keep so that they may review it at any time.
To Request a copy of your medical record: This right is not absolute if CCC believes that such access would cause harm, we can deny such a request. You do not have the right of access in the following instances:
There are other situations in which The Circle of Care Consultants, Inc. may deny you access to your medical record. If so, CCC is required to provide you with a review if the decision denying such access. Reviewable grounds for denial include but are not limited to:
For these reviewable grounds, another licensed professional must review the decision within 60 days. Their decision will be upheld.
The Circle of Care Consultants, Inc., RESPONSIBILITIES UNDER THE FEDERAL PRIVACY STANDARD
In addition to providing you your rights as detailed above CCC is required to:
Maintain the privacy of your PMHI: We will do this by the implementation of reasonable and appropriate physical, administrative and technical safeguards. Provide you with this notice: As to our legal duties and privacy practices with respect to the personal and private information we obtain about you during the course of your contract with The Circle of Care Consultants, Inc. Abide by the terms of this notice.
Train The Circle of Care Consultants, Inc. employees on our privacy and confidentiality policies.
Implement a disciplinary plan: The Circle of Care Consultants, Inc., has a course if disciplinary action for those CCC employees who breach our privacy/confidentiality policies. And if such a breach occurs, to lessen any resulting harm this breach may have caused.
The Circle of Care Consultants, Inc., will not use or disclose your personal and mental health information without your written consent/ authorization.
Maintain an account of any non-routine disclosures and uses of your medical records over the past 6 years beginning on April 14, 2003 within 60 days of such disclosures. Information provided will include name and address of who received your PMHI, a description of the information disclosed, and a statement of the purpose of such disclosure.
The Circle of Care Consultants, Inc., does not need to provide an account for:
If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in the paragraph below. You may contact us directly by email at email@example.com.
Grievances should be made in writing and be addressed to the attention of The Circle of Care Consultants, Inc., Privacy Officer. You also have the right to file a grievance with The U.S. Department of Health and Human Services. You may send a written complaint to the Secretary of the Department of Health and Human Services at Region IV, Office for Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW., Atlanta, Georgia 30303-8909. Voice Phone (404) 562-7886; Fax (404) 562-7881; TDD (404) 331-2867; E-mail: OCRComplaint@hhs.gov.
We will take no retaliatory action against you if you file a complaint about our privacy practices.
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact: Executive Director, Karen Rainer, CPS, CMHP, 4613 North University Drive, #561, Coral Springs, FL 33067, phone (561) 350-0310 or e-mail firstname.lastname@example.org.