As a provider of health services, Ravenwood Mental Health Center is legally obligated to follow regulations as it relates to the Health Insurance Portability and Accountability Act (HIPAA). This legislation outlines ways in which we may communicate your protected health information to other business associates, professionals, and service providers for the purposes of your health treatment, payment of services, and other healthcare operations. A copy of the agency Privacy Notice has been given to you, describing ways in which RMHC may, or may not divulge protected health information for these purposes.
The minimum amount of your protected health information necessary to carry out healthcare treatment, payment and health care operations will be released to outside entities. Business Associates and other healthcare providers are required, as well, to treat your protected health information with confidentiality under the HIPAA standards.
Ravenwood Mental Health Center reserves the right to change its privacy practices retroactively, and that the terms of the agency Privacy Notice may change. Any revisions in changed privacy practices can be obtained through contacting the Privacy Officer at this agency.
You have a right to request restrictions on how protected health information is used or disclosed to carry out your healthcare treatment, payment or healthcare operations. Ravenwood is not required to agree to those restrictions, but if Ravenwood does, those restrictions will be binding.
You have the right to revoke this document, in writing, except to the extent that Ravenwood Mental Health Center has taken action in the reliance on the consent. Otherwise this consent will remain valid for six years from the date of its creation.
Consumer signature: My signature on the acknowledgment verifies that I have received the agency's Notice of Privacy Practices, and I understand how my protected health information may be used for the purpose of treatment, payment, and/or healthcare operations.