Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations

Treatment. Your PHI may be used and disclosed by your physician, counselor, program staff and others outside of our program that are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and any related services. This includes coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care treatment. For example, your protected health information may be provided to the state agency that referred you to our program to ensure that you are participating in treatment. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of the program, becomes involved in your care.

Payment. We will not use your PHI to obtain payment for your health care services without your written authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.

Healthcare Operations. We may use or disclose, as needed, your PHI in order to support the business activities of our program including, but not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician or counselor. We may also call you by name in the waiting room when it is time to be seen. We may share your PHI with third parties that perform various business activities (e.g. billing or typing services), provided we have a written contract with the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI.

Rights Regarding Your Protected Health Information

• Your rights with respect to your protected health information are explained below. Any request with respect these rights must be in writing. A brief description of how you may exercise these rights is included.
• You have the right to inspect and copy your Protected Health Information
• You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the record. A “designated record set” contains medical and billing records and any other records that the program uses for making decisions about you. Your request must be in writing. We may charge you a reasonable cost-based fee for the copies. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right to appeal the denial of access. Please contact our team if you have questions about access to your medical record.
• You may have the right to amend your Protected Health Information
• You may request, in writing, that we amend your PHI that has been included in a designated record. 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. We may prepare a rebuttal to your statement and will provide you with a copy of it. Please contact The Forum if you have questions about amending your medical records.
• You have the right to receive an accounting of some types of Protected Health Information disclosures
• You may request an accounting of disclosures for a period of up to six years, excluding disclosures made to you, made for treatment purposes or made as a result of your authorization. We may charge you a reasonable fee if you request more than one accounting in any 12 month period. Please contact our team if you have questions about accounting of disclosures.
• You have the right to receive a paper copy of this notice
• You have the right to obtain a copy of this notice from us. Any questions should be directed to our team.
• You have the right to request added restrictions on disclosures and uses of your Protected Health Information
• You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or healthcare operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions. Please contact The Forum if you would like to request restrictions on the disclosure of your PHI.