HIPAA Form 1190-01
Effective Date: 4/14/03
Buckhorn Children & Family Services
PRIVACY NOTICE
THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.
· Your confidential information may be released to other healthcare professionals within Buckhorn Children & Family Services for the purpose of providing you with quality healthcare.
· Your confidential healthcare information may be released to insurance providers; contracting agencies or authorizing agencies for the purpose of receiving payment for providing you with needed healthcare services.
· Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.
· Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.
· Your sessions with treatment staff may be recorded for internal supervision purposes.
· Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).
· Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice.
· Your confidential healthcare information may be released only after receiving written authorization from you. You may revoke your permission to release confidential healthcare information at any time.
· You may be contacted by the Agency to remind you of treatment options or other services that may be of interest to you.
· You may be contacted by the Agency for the purposes of raising funds to support the Agency’s operations.
· You have the right to restrict the use of your confidential healthcare information. However, the Agency may choose to refuse your restriction if it is in conflict with providing you with quality care or in the event of an emergency situation.
· You have the right to receive confidential communication about your status.
· You have the right to review and photocopy any/all portions of your healthcare information.
· You have the right to know who has accessed your confidential healthcare information and for what purpose.
· You have the right to possess a copy of this Privacy notice upon request. This copy can be in the form of an electronic transmission or on paper.
· The Agency is required by law to protect the privacy of its clients. It will keep confidential any and all client healthcare information and will provide clients with a list of duties or practices that protect confidential healthcare information.
· The Agency will abide by the terms of this notice. The Agency reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information. Clients will receive a copy of any changes to this notice within 60 days of making the changes.
· You have the right to complain to the Agency if you believe your rights to privacy have been violated. If you feel your privacy rights have been violated, please mail your complaint to the Agency:
CEO
Buckhorn Children & Family Services
116 Buckhorn Lane
Buckhorn, Kentucky 41721
· All complaints will be investigated. No personal issue will be raised for filing a complaint with the Agency.
· For further information about this Privacy Notice, please contact:
Director of Administrative Services
Director Quality Assurance
(800) 472-3678
(502) 479-7339
· This notice is effective as of April 14, 2003.
Print Client Name:
_________________________________________________________
Client/Guardian/Parent Signature:
______________________________________________
Date: ___________________ Relationship: _______________________________