NOTICE OF PRIVACY PRACTICES
Effective: January 15, 2016
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.
This notice will tell you how we may use and disclose protected health information about you (your dependent). Protected health information means any health information about you that identifies you (your dependent) or for which there is a reasonable basis to believe the information can be used to identify you (your dependent).
In this notice, protected health information includes, but is not limited to: “preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure of unction of the body.” Family Outreach has determined that all confidential, identifiable information that is obtained about you (your dependent) will be designated as “protected health information.”
This notice also will tell you about your rights and our duties with respect to medical information about you (your dependent). In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
Your Rights With Respect to Medical Information About You
You have the following rights with respect to medical information that we maintain about you.
Right to Request Restrictions
You have the right to request that we restrict the uses or disclosures of protected health information about you (your dependent) 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 to public or private entities for disaster relief efforts. For example, you could ask that we not disclose medical information about you to your brother or sister.
Additional information regarding you protected health information (PHI) can be found at:
You may file a complaint with Family Outreach and/or to the United States Secretary of Health and Human Services if you believe your (your dependent’s) privacy rights have been violated by us.
To file a complaint with Family Outreach, contact: Tyler Tobol, Operations Manager, at 1236 Helena Ave. Helena, MT 59601 or to firstname.lastname@example.org. 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. Complaints also may be filed online. Go to: http://www.hhs.gov/ocr.
You will not be retaliated against for filing a complaint.