THIS SECTION DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective Date: April 14, 2003
The Crawford-Marion County Alcohol, Drug Addiction, & Mental Health Board (ADAMH Board) oversees
and pays for mental health and substance abuse treatment services for local citizens based upon need.
The benefits provided by the Board are available to residents through a network of providers. If you
are receiving this notice, our records indicate that our Board has been asked to pay or has paid for
services provided to you through one of our providers. Under federal law, our Board is required to
send you this notice describing how we can use and disclose the information we have collected and how
you can gain access to this information. Please review it carefully.
PROTECTING YOUR MEDICAL INFORMATION
The Crawford-Marion County ADAMH Board understands that medical information about you and your health
is personal. We are committed to protecting and safeguarding that information against unauthorized
use or disclosure. We are required by law to assure, medical information that identifies you is kept
private; give you Notice of our legal duties and privacy practices with respect to medical information
about you; and follow the terms of the Notice that is currently in effect. This Notice applies to all
records we have related to your care.
WHY WE COLLECT MEDICAL INFORMATION
We collect personal information to determine eligibility for health care coverage; provide benefits
and pay claims; conduct service evaluation of programs; and provide other information for planning and
improving mental health and substance abuse services in the community. We may also be required to
collect and keep certain information so that we meet legal and regulatory requirements; and we keep it
after the health care coverage ends.
TYPES OF INFORMATION WE COLLECT
You are asked to complete an enrollment form when seeking benefits that includes information such as:
name, address, phone, date of birth, marital status, social security number, and family income. We may
also receive information about you from others, such as doctors, clinics hospitals and other health care
providers; other Alcohol, Drug Addiction and/or Mental Health (ADAMH) Boards that provide coverage to our
clients or assist our board with its administrative functions; business partners that provide us with
products and services; and other government agencies such as the criminal justice system, child welfare
and juvenile justice. The information we collect from others may include for example, eligibility, claims
and payment information. We create and maintain a record of your enrollment in the public mental health
and or drug addiction and substance abuse system of the State of Ohio, and maintain records of payment
for treatment you receive in the public system. From time to time we may also receive information from
your treatment provider related to your diagnosis, treatment and progress in recovery, and any major
unexpected emergencies or crises you may experience that help the Board plan for and improve the quality
of services for the region’s citizens.
SAFEGUARDING YOUR PERSONAL INFORMATION
We maintain physical, electronic and procedural safeguards that comply with applicable federal and
state laws and regulations to guard your personal information against unauthorized use or disclosure.
Any third party processor or consultant used by the Board has signed an agreement with us requiring such
entity to maintain the confidentiality of your personal information. We also restrict access to your
personal information to those employees who need to know the information in order to perform their job
duties. The Board maintains policies and procedures that prohibit employees and agents of the Board
from using, disclosing, transferring, providing access to or otherwise divulging client health information
to any person or entity other than to the individual who is the subject of the information.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
We use and disclose Protected Health information (PHI) for a variety of reasons. We have limited right
to use and/or disclose your PHI for purposes of treatment, payment and for our health care opertions.
For uses beyond that, we must have your writen authorization unless the law permits or requires us to
make the use or disclosure without your authorization. If we disclose your PHI to an outside entity to
perform a function on our behalf, we must have in place an agreement from the outside entity that it will
extend the same degree of privacy protection to your information that we must apply to your PHI. However,
the law provides that we are permitted to make some uses/disclosures without your consent or authorization.
The following describes and offers some examples of our potential uses/disclosures of your PHI.
For treatment: We may disclose your PHI to doctors, counselors and other hospital and health
care personnel who are involved in providing your care. For example, information may be shared to
help members of your treatment team (including your doctor, nurse, casemanager, guardian, power of
attorney for health care) maximize and coordinate treatment benefits.
For payment: We may use and disclose your PHI to determine eligibility for plan benefits,
process and pay your claims and administer your health plan benefits. This may include determining
eligibility for co-pay, Medicaid or other sources of payment, reviewing submitted claims and processing
payment for those claims to your treatment agency.
For health care operations: We may use and disclose your PHI for required Board operations.
For example, we may conduct an audit to evaluate the quality of the services you receive and/or make
plans to better serve the community through mental health and alcohol or other drug services, investigate
and report major unusual incidents, and make reports as required by state departments.
Business Partners: We may disclose your PHI to a Business Partner in order for that entity
to perform a function on our behalf, such as administering benefits and services. We must have in
place an agreement from the Business partner that extends the same degree of privacy protection to
your information that the Board must apply.
Authorized representatives: This may include parents and guardians, or persons who have legal
authority to make health care decisions on your behalf.
Other uses:
For research purposes: For instance, if a waiver of authorization has been obtained in order
to assist in medical research.
For Public Health activities: For instance, when we are required to report information about
disease or injury, or to report vital statistics to the public health authority.
Relating to decedents: For instance, information relating to a death to coroners, medical
examiners or funeral directors.
As required by law: For instance, when a law requires that we report information about
suspected abuse, neglect or domestic violence, or relating to suspected criminal activity.
To avert a serious threat to Health or Safety: For instance, to law enforcement or other
persons who can reasonably prevent or lessen the threat of harm to the health or safety of a person
or the general public.
For Specific Government Functions: For instance, to military personnel and veterans in certain
situations, to correctional facilities, to government benefit programs relating to eligibility and
enrollment, for national security reasons, such as protection of the President.
Worker’s Compensation: For instance, to comply with the laws relating to worker’s compensation
or other similar programs.
Lawsuits and Disputes: For instance, in the course of judicial and administrative
proceedings.
Law Enforcement and Regulatory authorities: For instance, as required by law in response
to a court order.
National Security and Intelligence Activities: For instance, for national security reasons,
such as protection of the President.
For any other types of disclosures to third parties, we require a client, guardian or a parent of a
minor to complete a release of authorization. Authorizations can be revoked at any time to stop
future uses/disclosures except to the extent that we have already undertaken an action in reliance
upon your authorization.
“OPTING OUT” OF INFORMATION SHARING
You may have received Notices of Privacy Practices from treatment providers or other organizations
that allow you to “opt out” of certain disclosures. A common type of disclosure to which “opt outs”
apply is the disclosure of personal information at a hospital information desk that allows visitors
to know where you are and your general condition. As a health plan, the Crawford-Marion County ADAMH
Board must follow many federal and state laws that prohibit us from making these types of disclosures.
Because we do not make disclosures to which “opt outs” apply, it is not necessary for you to complete
an “opt out” form or take any action to restrict such disclosures.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding health information:
To Request Restrictions: You have a right to request a restriction or limitation on the use
and disclosure of your PHI. We will consider your request however, we are not legally bound to
agree to the restriction. We cannot agree to limit uses/disclosures that are required by law.
To Choose How We Contact You: You have the right to request confidential communications through
a reasonable alternative means or at an alternative location. For instance, you can ask that we only
contact you by mail, at work.
To Inspect and Copy: You have a right to inspect and copy your personal information unless
the access to your records is restricted for clear and documented treatment reasons. For instance,
we may not share information if the information is the subject of a lawsuit or legal claim or if
release of the information may present a danger to you or someone else. Your request must be in
writing and we will provide you with a written response within 30 days of your request. If your
request is denied, we will also give you a written explanation of the reason for the denial.
To request an amendment: You have a right to request an amendment if you believe there is
a mistake or missing information. We will respond within 60 days of receiving your written request.
We may deny the request if we determine the information is correct and complete; not created by us
and/or not part of our records, or; not permitted to be disclosed. If we approve the request for
amendment, we will notify you of the change and inform others that need to know about the change
in your information.
To receive an accounting of disclosures: You have a right to request an accounting of the
disclosures of your PHI that has been released for purposes other than treatment, payment or health
care operations; to you, or pursuant to your written authorization. The list will not include any
disclosures made for national security purposes, to law enforcement officials or correctional
facilities, when the information is subject to a lawsuit, is a danger to you or someone else or
disclosures made before April 14, 2003.
To receive a paper copy of this notice: You have a right to a paper copy of this Notice by
contacting the Board office. This Notice is also available at our web site: www.mcadamh.com
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed
Notice effective for medical information we already have about you as well as any information we
receive in the future. A copy of the current Notice will be posted at the Board office. In
addition, each time there is a change in the Notice, you will receive a copy by mail at the last
known address we have in our plan enrollment file.
OTHER USES OF PERSONAL HEALTH INFORMATION
Other uses and disclosures of your personal health information not covered by this Notice or the
laws that apply to us will be made only with your written permission. If you provide us permission
to use or disclose health information about you, you may revoke that permission, in writing, at any
time. If you revoke your permission, we will no longer use or disclose your health information for
the reasons covered by your written permission. You understand that we are unable to take back any
disclosures we have already made with your permission, and that we are required to retain our records
of the services that we provided to you.
COMPLAINTS ABOUT OUR PRIVACY PRACTICES
If you have a complaint about our privacy practices or if you believe your privacy rights have been
violated, you may file a complaint with the Board’s Privacy Officer at the address below or with the
Secretary of the Department of Health and Human Services. We will not retaliate against you in any
way for filing a complaint.
Contact Person to Exercise Your Rights, for Additional Information or to Submit a Complaint:
Privacy Officer - Crawford-Marion County Alcohol, Drug Addiction, & Mental Health Board
142 South Prospect Street, Marion, OH 43302
Phone: 740-387-8531 |
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Related Pages
Client Rights
Involuntary Hospitalization
Agencies you may contact to file a complaint/grievance:
Crawford-Marion ADAMH Board
142 South Prospect Street
Marion, OH 43302
740-387-8531
Ohio Department of Mental Health
30 East Broad Street, 8th Floor
Columbus, OH 43215-3430
614-466-2596
Ohio Legal Rights Service
8 East Long Street, 5th Floor
Columbus, OH 43215-2999
800-282-9181
614-466-7264
Attorney General’s Office, Medicaid Fraud Control Section
30 East Broad Street, 17th Floor
Columbus, OH 43215-3428
614-466-4320
Office for Civil Rights
Cleveland Office
U. S. Department of Education
600 Superior Avenue East Bank One Center, Room 750
Cleveland, OH 44114-2611
216-522-4970
Ohio Counselor and Social Worker Board
77 South High Street, 16th Floor
Columbus, OH 43215-6108
614-466-0912
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