Mountain Regional Services
Inc.
(MRSI)
Also dba Cornerstone Behavioral Health
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT
CAREFULLY
This notice will tell you how we may use and disclose
protected health information about you. Protected health
information means any health information about you that
identifies you or for which there is a reasonable basis to
believe the information can be used to identify you.
This notice also will tell you about your rights and our
duties with respect to protected health information about you.
In addition, it will tell you how to complain to us if you
believe we have violated your privacy rights.
How We May Use and Disclose Protected Health Information
About You.
We use and disclose protected health
information about you for a number of different purposes. Each
of those purposes is described below.
. For Treatment (45 CFR 164.520 (b)(1)(ii)(A)
We
may use protected health information about you to provide,
coordinate or manage your health care and related services by
both us and other health care providers. We may disclose
protected health information about you to doctors, nurses,
hospitals and other health facilities who become involved in
your care. We may consult with other health care providers
concerning you and as part of the consultation share your
protected health information with them. Similarly, we may refer
you to another health care provider and as part of the referral
share protected health information about you with that provider.
For example, we may conclude you need to receive services from a
physician with a particular speciality. When we refer you to
that physician, we also will contact that physician's office and
provide protected health information about you to them so they
have information they need to provide services for you.
. For Payment. (45 CFR 164.520 (b)(1)(ii)(A)
We may
use and disclose protected health information about you so we
can be paid for the services we provide to you. This can include
billing you, your insurance company, or a third party payer. For
example, we may need to give your insurance company information
about the health care services we provide to you so your
insurance company will pay us for those services or reimburse
you for amounts you have paid. We also may need to provide your
insurance company or a government program, such as Medicare or
Medicaid, with information about your medical condition and the
health care you need to receive to obtain and determine if you
are covered by that insurance or program.
.For Health Care Operations. (45 CFR 164.520 (b) (1)
(ii) (A)
We may use and disclose protected health
information about you for our own health care operations. These
are necessary for us to operate MRSI and to maintain quality
health care for our patients. For example, we may use protected
health information about you to review the services we provide
and the performance of our employees in caring for you. We may
disclose protected health information about you to train our
staff and students working with MRSI. We may also use the
information to study ways to more efficiently manage our
organization.
. How we will contact you.
Unless you tell us
otherwise in writing, we may contact you by either telephone or
by mail at either your home or your office. At either location,
we may leave messages for you on the answering machine or voice
mail. If you want to request that we communicate to you in a
certain way or at a certain location, see "Right to Receive
Confidential Communications" on page 5 of this Notice.
. Appointment Reminders. (45 CFR 164.520 (b) (1) (iii)
(A)
We may use and disclose protected health information
about you to contact you to remind you of an appointment you
have with us.
. Treatment Alternatives. (45 CFR 164.520 (b) (1)
(iii) (A)
We may use and disclose protected health
information about you to contact you about treatment
alternatives that may be of interest to you.
. Health Related Benefits and Services. (45 CFR
164.520 (b) (1) (iii) (A)
We may use and disclose protected
health information about you to contact you about health related
benefits and services that may be of interest to you.
. Individuals Involved in Your Care. (45 CFR 164.510
(b)
We may disclose to a family member, other relative, a
close personal friend, or any other person identified by you,
protected health information about you that is directly relevant
to that person's involvement with your care or payment related
to your care. We also may use or disclose protected health
information about you to notify, or assist in notifying, those
persons of your location, general condition, or death. If there
is a family member, other relative, or close personal friend
that you do not want us to disclose protected health information
about you, please notify or tell our staff member who is
providing care to you.
. Disaster Relief. (45 CFR
164.510 (b) (4)
We may use or disclose protected health
information about you to a public or private entity authorized
by law or by its charter to assist in disaster relief efforts.
This will be done to coordinate with those entities in notifying
a family member, other relative, close personal friend, or other
person identified by you of your location, general condition or
death.
. Required by Law. (45 CFR 164.512
(a)
We may use or disclose protected health information about
you when we are required to do so by law.
. Public Health Activities. (45 CFR 164.512 (b)
We
may disclose protected health information about you for public
health activities and purposes. This includes reporting medical
information to a public health authority that is authorized by
law to collect or receive the information for purposes of
preventing or controlling disease. Or, one that is authorized to
receive reports of child abuse and neglect.
. Victims of Abuse, Neglect or Domestic Violence.
(45 CFR 164.512©
We may disclose protected health
information about you to a government authority authorized by
law to receive reports of abuse, neglect, or domestic violence,
if we believe you are a victim of abuse, neglect, or domestic
violence. This will occur to the extent the disclosure is: (a)
required by law; (b) agreed to by you; or,(c) authorized by law
and we believe the disclosure is necessary to prevent serious
harm to you or to other potential victims, or, if you are
incapacitated and certain other conditions are met, a law
enforcement or other public official represents that immediate
enforcement activity depends on the disclosure.
. Health Oversight Activities. (45 CFR
164.512(d)
We may disclose protected health information about
you to a health oversight agency for activities authorized by
law, including audits, investigations, inspections, licensure or
disciplinary actions. These and similar types of activities are
necessary for appropriate oversight of the health care system,
government benefit programs, and entities subject to various
government regulations.
. Judicial and Administrative Proceedings. (45 CFR
164.512 (e)
We may disclose protected health information
about you in the course of any judicial or administrative
proceeding in response to an order of the court or
administrative tribunal. We also may disclose protected health
information about you in response to a subpoena, discovery
request, or other legal process but only if efforts have been
made to tell you about the request or to obtain an order
protecting the information to be disclosed.
. Disclosures for Law Enforcement Purposes. (45
CFR 164.512(f)
We may disclose protected health information
about you to a law enforcement official for law enforcement
purposes:
a. As required by law.
b. In response to a court,
grand jury or administrative order, warrant or subpoena.
c. To identify or locate a suspect, fugitive, material
witness or missing person.
d. About an actual or suspected victim of a crime and that
person agrees to the disclosure. If we are unable to obtain
that person's agreement, in limited circumstances, the
information may still be disclosed.
e. To alert law enforcement officials to a death if we
suspect the death may have resulted from criminal conduct.
f. About crimes that occur at our facility.
g. To report a crime in emergency
circumstances.
. Coroners and Medical Examiners. (45 CFR 164.512 (g)
(1)
We may disclose protected health information about you to
a coroner or medical examiner for purposes such as identifying a
deceased person and determining cause of death.
. Funeral Directors. (45 CFR 164.512 (g)(2)
We may
disclose protected health information about you to funeral
directors as necessary for them to carry out their duties.
. Organ, Eye or Tissue Donation. (45 CFR 164.512
(h)
To facilitate organ, eye or tissue donation and
transplantation, we may disclose protected health information
about you to organ procurement organizations or other entities
engaged in the procurement, banking or transplantation of
organs, eyes or tissue.
. Research. (45 CFR 164.512 (I)
Under certain
circumstances, we may use or disclose protected health
information about you for research. Before we disclose protected
health information for research, the research will have been
approved through an approval process that evaluates the needs of
the research project with your needs for privacy of your
protected health information. We may, however, disclose
protected health information about you to a person who is
preparing to conduct research to permit them to prepare for the
project, but no protected health information will leave MRSI
during that person's review of the information.
. To Avert Serious Threat to Health or Safety. (45 CFR
164.512)(j)
We may use or disclose protected health
information about you if we believe the use or disclosure is
necessary to prevent or lessen a serious or imminent threat to
the health or safety of a person or the public. We also may
release information about you if we believe the disclosure is
necessary for law enforcement authorities to identify or
apprehend an individual who admitted participation in a violent
crime or who is an escapee from a correctional institution or
from lawful custody.
. Military. (45 CFR 164.512 (k) (1)
If you are a
member of the Armed Forces, we may use and disclose protected
health information about you for activities deemed necessary by
the appropriate military command authorities to assure the
proper execution of the military mission. We may also release
information about foreign military personnel to the appropriate
foreign military authority for the same purposes.
. National Security and Intelligence. (45 CFR 164.512
(k)(2)
We may disclose protected health information about you
to authorized federal officials for the conduct of intelligence,
counter-intelligence, and other national security activities
authorized by law.
. Protective Services for the President. (45 CFR
164.512 (k) (3)
We may disclose protected health information
about you to authorized federal officials so they can provide
protection to the President of the United States, certain other
federal officials, or foreign heads of state.
. Inmates; Persons in Custody. (45 CFR 164.512 (k)
(5)
We may disclose protected health information about you to
a correctional institution or law enforcement official having
custody of you. The disclosure will be made if the disclosure is
necessary: (a) to provide health care to you; (b) for the health
and safety of others; or, (c) the safety, security and good
order of the correctional institution.
. Workers Compensation. (45 CFR 164.512(l)
We may
disclose protected health information about you to the extent
necessary to comply with workers' compensation and similar laws
that provide benefits for work-related injuries or illness
without regard to fault.
. Other Uses and Disclosures.
Other uses and
disclosures will be made only with your written authorization.
You may revoke such an authorization at any time by notifying
MRSI, P.O. Box 6005, Evanston, WY. 82931, in writing of your
desire to revoke it. However, if you revoke such an
authorization, it will not have any affect on actions taken by
us in reliance on it.
Your Rights With Respect to Medical
Information About You.
You have the following rights with respect to protected
health information that we maintain about you.
. Right to Request Restrictions. (45 CFR 164.520 (b)
(iv) (A); 45 CFR 164.522(a) (1)
You have the right to request
that we restrict the uses or disclosures of protected health
information about you to carry out treatment, payment, or health
care operations. You also have the right to request that we
restrict the uses or disclosures we make to: (a) a family
member, other relative, a close personal friend or any other
person identified by you; or, (b) for public or private entities
for disaster relief efforts. For example, you could ask that we
not disclose protected health information about you to your
brother or sister.
To request a restriction, you may do so at the time you
complete your consent form or at any time after that. If you
request a restriction after that time, you should do so in
writing to MRSI P.O. Box 6005, Evanston, WY. 82931, and tell
us:(a) what information you want to limit; (b) whether you want
to limit use or disclosure or both; and, (c) to whom you want
the limits to apply (for example, disclosures to your
spouse).
We are not required to agree to any requested restriction.
However, if we do agree, we will follow that restriction unless
the information is needed to provide emergency treatment. Even
if we agree to a restriction, either you or we can later
terminate the restriction.
. Right to Receive Confidential Communications. (45
CFR 164.520 (b) (iv) (B); 45 CFR164.522(b)(1)
You have the
right to request that we communicate protected health
information about you to you in a certain way or at a certain
location. For example, you can ask that we only contact you by
mail or at work. We will not require you to tell us why you are
asking for the confidential communication.
If you want to request confidential communication, you must
do so in writing to President, MRSI P.O. Box 6005, Evanston, WY.
82931. Your request must state how or where you can be
contacted.
We will accommodate your request. However, we may, when
appropriate, require information from you concerning how payment
will be handled.
. Right to Inspect and Obtain a Copy. (45 CFR 164.520
(b) (iv) (C); 45 CFR 164.524)
With a few very limited
exceptions, such as psychotherapy notes, you have the right to
inspect and obtain a copy of protected health information about
you. To inspect or obtain a copy of protected health information
about you, you must submit your request in writing to President,
MRSI, P.O. Box 6005, Evanston, WY. 82931. Your request should
state specifically what protected health information you want to
inspect or obtain a copy. If you request a copy of the
information, we may charge a fee for the costs of copying and,
if you ask that it be mailed to you, the cost of mailing.
We will act on your request within thirty (30) calendar days
after we receive your request. If we grant your request, in
whole or in part, we will inform you of our acceptance of your
request and provide access and copying.
We may deny your request to inspect and copy protected health
information if the protected health information involved is:
a. Psychotherapy notes;
b. Information compiled in
anticipation of, or use in, a civil, criminal or
administrative action or proceeding;
If we deny your request, we will inform you of the basis for
the denial, how you may have our denial reviewed, and how you
may complain. If you request a review of our denial, it will be
conducted by a licensed health care professional designated by
us who was not directly involved in the denial. We will comply
with the outcome of that review.
. Right to Amend. (45 CFR 164.520 (b) (iv) (D); 45CFR
164.526)
You have the right to ask us to amend protected health
information about you.
You have this right for as long as the
protected health information is maintained by us.
To request an amendment, you must submit your request in
writing to; President, MRSI P.O. Box 6005, Evanston, WY. 82931.
Your request must state the amendment desired and provide a
reason in support of that amendment.
We will act on your request within sixty (60) calendar days
after we receive your request. If we grant your request, in
whole or in part, we will inform you of our acceptance of your
request and provide access and copying.
If we grant the request, in whole or in part, we will seek
your identification of and agreement to share the amendment with
relevant other persons. We will also make the appropriate
amendment to the protected health information by appending or
otherwise providing a link to the amendment.
We may deny your request to amend protected health
information about you. We may deny your request if it is not in
writing and does not provide a reason in support of the
amendment. In addition, we may deny your request to amend
protected health information if we determine that the
information:
a. Was not created by us, unless the person or entity that
created the information is no longer available to act on the
requested amendment;
b. Is not part of the protected health information
maintained by us:
c. Would not be available for you to inspect or copy;
or,
d. Is accurate and complete.
If we deny your request, we will inform you of the basis for
the denial. You will have the right to submit a statement of
disagreement with our denial. Your statement may not exceed 10
pages. We may prepare a rebuttal to that statement. Your request
for amendment, our denial of the request, your statement of
disagreement, if any, and our rebuttal, if any, will then be
appended to the protected health information involved or
otherwise linked to it. All of that will then be included with
any subsequent disclosure of the information, or, at our
election, we may include a summary of any of that
information.
If you do not submit a statement of disagreement, you may ask
that we include your request for amendment and our denial with
any future disclosures of the information. We will include your
request for amendment and our denial (or a summary of that
information) with any subsequent disclosure of the protected
health information involved.
You also will have the right to complain about our denial of
your request.
. Right to an Accounting of Disclosures. (45 CFR
164.520 (b)(iv)(E); 45 CFR 164.528)
You have the right to
receive an accounting of disclosures of protected health
information about you. The accounting may be for up to six (6)
years to the date on which you request the accounting but not
before April 14, 2003.
Certain types of disclosures are not included in such an
accounting:
a. Disclosures to carry out treatment,
payment and health care operations;
b. Disclosures of your protected health information made to
you;
c. Disclosures for national security or intelligence
purposes;
d. Disclosures to correctional institutions or law
enforcement officials;
e. Disclosures made prior to April 14, 2003.
Under certain circumstances your right to an accounting of
disclosures may be suspended for disclosures to a health
oversight agency or law enforcement official.
To request
an accounting of disclosures, you must submit your request in
writing to President, MRSI, P.O. Box 6005, Evanston, WY. 82931.
Your request must state a time period for the disclosures. It
may not be longer than six (6) years from the date we receive
your request and may not include dates before April 14, 2003.
Usually, we will act on your request within sixty (60)
calendar days after we receive your request. Within that time,
we will either provide the accounting of disclosures to you or
give you a written statement of when we will provide the
accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you
in any twelve (12) month period. For additional accountings, we
may charge you for the cost of providing the list. If there will
be a charge, we will notify you of the cost involved and give
you an opportunity to withdraw or modify your request to avoid
or reduce the fee.
. Right to Copy of this Notice. (45 CFR 164.520 (b)
(iv) (F)
You have the right to obtain a paper copy of our
Notice of Privacy Practices. You may obtain a paper copy even
though you agreed to receive the notice electronically. You may
request a copy of our Notice of Privacy Practices at any
time.
You may obtain a copy of our Notice of Privacy Practices over
the Internet at our web site, www.mrsi.org .
To obtain a paper copy of this notice, contact MRSI, P.O. Box
6005, Evanston, WY. 82931, 307-789-3710.
Our Duties
. Generally.
We are required by law to maintain
the privacy of protected health information about you and to
provide individuals with notice of our legal duties and privacy
practices with respect to protected health information. (45 CFR
164.520 (b) (v)(A)
We are required to abide by the terms of our Notice of
Privacy Practices in effect at the time.(45CFR 164.520 (b) (v)
(B)
. Our Right to Change Notice of Privacy
Practices.
We reserve the right to change this Notice of
Privacy Practices. We reserve the right to make the new notice's
provisions effective for all protected health information that
we maintain, including that created or received by us prior to
the effective date of the new notice. (45 CFR 164.520 (b) (v)
(C).
. Availability of Notice of Privacy Practices.
A copy of
our current Notice of Privacy Practices will be posted in our
Wyoming facilities. A copy of the current notice also will be
posted on our web site, www.mrsi.org . In addition, each time
you are admitted to services at MRSI, a copy of the current
notice will be made available to you.
At any time, you may obtain a copy of the current Notice of
Privacy Practices
by contacting MRSI, P.O. Box 6005,
Evanston, WY. 82931, #307-789-3710.
. Effective Date of Notice.
The effective date of
the notice will be stated on the first page of the notice.
. Complaints.
You may complain to us and to the
United States Secretary of Health and Human Services if you
believe your privacy rights have been violated by us.
To file a complaint with us, contact President, MRSI, P.O.
Box 6005, Evanston, WY. 82931, 307-789-3710. All complaints
should be submitted in writing.
To file a complaint with the United States Secretary of
Health and Human Services, send your complaint to him or her in
care of: Office for Civil Rights, U.S. Department of Health and
Human Services, 200 Independence Avenue SW, Washington, D.C.
20201.
You will not be retaliated against for filing a
complaint.
. Questions and Information.
If you have any
questions or want more information concerning this Notice of
Privacy Practices, please contact President, MRSI, P.O. Box
6005, Evanston, WY 82931.