THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE PORTABLILITY AND ACCOUNTABILITY ACT OF 1996 (HIPPA) that prescribes legal duties and privacy practices to protect the privacy of your individual identifiable health information; this is, Protected Health Information (PHI), as that term is defined in the HIPPA under Information.
THE EFFECTIVE DATE OF THIS NOTICE IS APRIL 14, 2003. Journey Assistance Counseling (JAC) is required to follow the terms of this Notice until it is replaced. JAC may
make changes to the terms of this Notice at any time. Upon your request, we will provide you with a copy of the current Notice. JAC reserves the right to make the changes apply to your Information maintained in our files before, and after, the effective date of the new Notice. The following is a general description of how Federal and State law permits us to use and disclose your Information. Purposes for which JAC May Use or Disclose Your Mental Health Information with
Your Consent to Treatment
Treatment. JAC will use and disclose your Information to provide, coordinate, or manage your mental health care and any related services. JAC may disclose your Information to
physicians, therapists, other mental health providers, or other health care providers who are treating you or assisting in your diagnosis, treatment or recovery.
Payment. Your Information will be used and disclosed, as needed, to obtain payment for your mental health care services. This may include certain activities that your health insurance plan undertakes before it approves or pays for the mental 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 utilization review activities. If more than one third-party payer is responsible for payment for your health care, JAC may disclose your Information to more than one health plan and those health plans may share your Information with each other. Your Information may also be used and disclosed as
needed to obtain payment for mental health care services rendered to you by other providers.
Mental Health Care Operations. JAC may use or disclose, as needed, your Information in order to support delivery of mental health care services. JAC may call you by name in the waiting room area. JAC may use or disclose your Information, as necessary, to contact you to schedule an appointment or remind you of your appointment.
JAC may share your Information with third party Business Associates who perform various administrative services. For example, those within JAC, or with whom JAC contracts, who perform billing services, transcription services, record retention, or other professional
consultants. Whenever an arrangement between a Business Associate and JAC involves the use or disclosure of your Information, we will have a written contract that contains terms that will protect the privacy of your Information.
Business Associates: JAC may share your information with third party Business Associates who perform various administrative services. Whenever an arrangement between a Business Associated and JAC involves the use or disclosure of your information, we will have a written
contract that contains terms that will protect the privacy of your information.
Health Care Services. Your Information may be used and disclosed to contact you and to give you information about treatment alternatives or other health benefits and services that may be of interest to you.
Uses and Disclosures With Your Written Authorization
Except as provided below, your Information will not be used for any non-routine purposes unless you give your written authorization to do so. If you give written authorization to use or disclose your Information for a purpose that is not described in this Notice, then, with certain exception, you
may revoke it in writing at any time. Your revocation will be effective for the Information JAC maintains, unless JAC has taken action in reliance on your authorization.
Uses and Disclosures Without Your Consent
As required by law
To comply with legal proceedings, such as a court or administrative order or subpoena To law enforcement officials for limited law enforcement purposes
To avert a serious threat to your health or safety or the health or safety of others To a governmental agency authorized to oversee the mental health care system or
government programs To federal officials for lawful intelligence, counterintelligence, and other national security purposes To public mental health authorities for public health purposes
You may make a written request to JAC to do one or more of the following concerning your
Put additional restrictions on use and disclosure of your Information
Communicate with you in confidence about your Information by a different means than JAC
is currently doing
See and get copies of your Information, including this notice
Receive a list of disclosures of your Information that JAC has made for certain purposes,
which includes exceptions for disclosure made directly to you or made pursuant to your
If you want to exercise any of these rights or require further information about privacy practices, please contact me at the address above. JAC is not required in all instances to agree to your request for release of information to third parties. Should we agree to provide information to a third
party, JAC will give you the necessary information and forms for you to complete and return to request your Information. JAC is permitted, by law, to charge you a fee for copying any documents requested in accordance with your rights as listed above. (Fee $2.00 per page, and is subject to change.)
If you believe that JAC violated your privacy rights, you have the right to complain to me or to the Secretary of the U.S. Department of Health and Human Services (DHHS). You may file a written complaint with me at the address above. An individual must file a complaint within 180 days of when he/she knew or should have known that the act or omission occurred, unless the time limit is waived by the Secretary of DHHS. JAC will not retaliate against you if you choose to file a complaint.
PRIVACY NOTICE ACKNOWLEDGEMENT
As a client of Journey Assistance Counseling, I acknowledge that I have been given the Privacy
Notice required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of my individually identifiable health information, by Journey Assistance Counseling.