THIS NOTICE DESCRIBES HOW ClearPath Family Healthcare (CP) MIGHT USE AND DISCLOSE INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. Introduction At ClearPath Family Healthcare (CP), we are committed to treating and using Protected Health Information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your individual rights as they relate to your Protected Health Information. This Notice is effective Jan 1, 2021 and applies to all Protected Health Information as defined by federal regulations. Understanding Your Health Record/Information Each time you visit CP, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your chart or medical record, serves as a:
•Basis for planning your care and treatment;
•Means of communication among the many health professionals who contribute to your care;
•Legal document describing the care you received;
•Means by which you or a third-party payer can verify that services billed were actually provided;
Tool in educating health professionals;
Source of data for medical research;
Source of information for public health officials charged with improving the health of this state and the nation;
Source of data for our planning and marketing; and Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Your Health Information Rights Although your health record is the physical property of CP, the information belongs to you. You have the following rights:
Right to a Paper Copy of this Notice. You may ask us to give you a copy of this Notice at any time.
Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances.
Right to Amend. You may request that we amend the Protected Health Information CP has about you if you feel it is incorrect or incomplete. You may request an amendment for as long as the information is kept by the practice.
Right to an Accounting of Disclosures. You may request an “accounting of disclosures.” This is a list of the disclosures CP has made of Protected Health Information about you.
Right to Request Confidential Communications. You may request that we communicate with you about medical matters in a certain way or at a certain location.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Right to Revoke Your Authorization. You may revoke your authorization to use or disclose Protected Health Information except to the extent that the action has already been taken.
Right to Opt out. We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications. Right to Receive Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
Out-of-Pocket Payments. If you paid out-of- in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
Maintain the privacy of your health information.
Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. Abide by the terms of this Notice.
Notify you if we are unable to agree to a requested restriction.
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve the right to change our policy and to make the new provisions effective for all protected health information we maintain. You are entitled to a paper copy of our Notice of Privacy Practices at any time at your request. We will not use or disclose your Protected Health Information without your authorization, except as described in this Notice. We will also discontinue using or disclosing your Protected Health Information after we have received a written revocation of your authorization. For More Information or to Report a Problem If you have questions, would like additional information, or believe your privacy rights have been violated, you can contact the: ClearPath Family Healthcare LTD Attn: Shaun Romero 7725 N. 43rd Ave Suite 720Phoenix, AZ 85051623-207-5465
Examples of Disclosures and Uses of Your Protected Health Information Treatment. We may use Protected Health Information about you to provide you with medical treatment or services. We may disclose Protected Health Information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the practice or the hospital. For example, we may disclose Protected Health Information about you to people outside the practice who may be involved in your medical care, such as family members, clergy, or other persons who are part of your care. Payment. We may use and disclose Protected Health Information about you so that the treatment and services you receive at the practice may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may disclose your record to an insurance company, so that we can get paid for treating you; we may disclose your account information to our third-party business associates for payment(s). Healthcare Operations. We may use and Protected Health Information about you for healthcare operations. These uses and disclosures are necessary to run the practice and provide your healthcare. We also may disclose information to doctors, nurses, technicians, medical students, and other practice personnel for review and learning purposes. For example, we may review your record to assist our quality improvement efforts.
Business Associates. There are some services provided in our organization through contacts with business associates. An example is certain tests performed by outside laboratories. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associates to appropriately safeguard your information. Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose Protected Health Information to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
As Required by Law. We will disclose Protected Health Information about you when required to do so by international, federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.
Workers’ Compensation. We may use or disclose Protected Health Information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law enforcement: We may disclose Protected Health Information for law enforcement purposes as required by law or in response to a valid subpoena.
Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or if we are required or authorized by law to make that disclosure.
Military and Veterans. If you are a member of the armed forces, we may disclose Protected Health Information as required by military command authorities. We also may disclose Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Behavioral Health Consent for Treatment:
Purpose of Treatment
The purpose of meeting with a Behavioral Health Manager is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. It is important to take care of both your mind and your body. Your BHM will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to your BHM about the issues that are bothering you. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust. Privacy, also called confidentiality, is an important and necessary part of good treatment.
Expectations of Confidentiality:
As a general rule, BHMs will keep the information you share with them in sessions confidential. There are, however, important exceptions to this rule that are important for you to understand before you share personal information. In some situations, BHMs are required by law or by the guidelines of our profession to disclose information whether or not you have given your permission. Please see the list of some of these situations below.
Exceptions to Confidentiality:
· In your doctor’s office, we work together as a team. Therefore, your information may be shared with your provider and/or with our psychiatric consultant, for treatment purposes.
· You tell your BHM that you plan to cause serious harm or death to yourself, and your BHM believes you have the intent and ability to carry out this threat in the very near future.
· You tell your BHM that you plan to cause serious harm or death to someone else who can be identified, and your BHM believes you have the intent and ability to carry out this threat in the very near future.
· You tell your BHM that you are being abused physically, sexually or emotionally, or that you have been abused in the past. In this situation, your BHM is required by law to report the abuse to the Department of Child Safety and possibly the police.
· Additional circumstances under which confidentiality is not maintained include supervision and consultation. Clinical Supervisor: Jeffrey Ainsa, LCSW
· All other discussions will occur only when a Release of Information Form has been completed, identifying who the information is to be released to and what specific information is to be released.
Relationship with the Behavioral Health Manager
The relationship between you and your BHM will be limited to the relationship of BHM and patient only. There are important differences between treatment and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions. A BHM offers you choices and helps you consider what is best for you. BHMs are required to keep the identity of their patient confidential. Therefore, your BHM
may not acknowledge you when you meet in a public place, and must decline to attend your family’s gatherings if invited. Lastly, when treatment is completed, your BHM will not be able to be a friend to you like your other friends. In sum, your BHM’s duty is to care for you and other patients, but only in the professional role of BHM. Your BHM is not permitted to give or to receive gifts from patients except tokens with personal meaning to the treatment process.
Treatment Risks and Benefits
Approaches that are commonly utilized by your BHM include cognitive behavioral therapy (CBT), and dialectical behavior therapy (DBT). At times, and if deemed clinically appropriate and necessary, your BHM may administer a variety of screening and assessment tools. Your signature indicates your consent to allow your BHM to administer these instruments as clinically indicated.
Treatment goals are identified and discussed with you after the initial meeting, and as a patient it is your responsibility to participate in working toward the goals set. Emotional risks involved in treatment include disclosing personal feelings, talking about life experiences which may at times be painful or upsetting, asking for help and assistance, expressing emotions such as affection, anger, fear, and sadness, receiving emotional support, and receiving positive and constructive feedback. In addition, there is the potential for therapeutic services rendered to result in no benefit to the patient.
Termination of services may occur as the result of meeting identified goals and objectives or your desire to discontinue participation in this service. When your identified goals have been attained, then you will collaborate to identify a plan through which services can be closed in a manner that is supportive and therapeutic for you.
At times changes in eligibility will impact a patient’s healthcare coverage. In the event that a change in eligibility occurs, you will be notified of this change and offered the opportunity to continue services on a private pay basis until eligibility can be restored. Should you be unable to pay this fee, a referral will be made for alternative free or low cost mental health services that may be available to you.
It is your responsibility to ensure that sessions are kept. If you are not able to attend a pre-scheduled session, you are to contact your provider’s office at least 24 hours before your session to cancel or reschedule.
All of your records will be kept in a secure location. If you would like a copy of any records, please follow the procedure of your doctor’s office to request records.
Afterhours Resources and Emergency Response
Should a life-threatening emergency develop at any time, please contact 911.