This notice describes how you can access your personal medical information and how we may use and disclose it to provide you with services. PLEASE REVIEW IT CAREFULLY. If you have any questions about this Notice, please contact Riverbend’s Privacy Officer at (603)226-7505 x 4335 or firstname.lastname@example.org. RIVERBEND’S COMMITMENT TO PRIVACY Riverbend Community Mental Health, Inc. (Riverbend) is committed to insure the privacy and confidentiality of the personally identifiable protected health information (PHI) it creates and maintains regarding the clients that it serves. Confidence in the privacy of the sensitive information clients share with staff promotes partnership, honest and open dialogue, and facilitates appropriate clinical supports to aid the client in his or her recovery and healthy development. Riverbend takes steps to assure that only those individuals who have a legitimate need have access to your health information to accomplish their work assignments. All staff in Riverbend’s programs and offices throughout Merrimack County will follow this notice. Riverbend is required by law to maintain the privacy of your personally identifying health information and to provide you with this Notice. We are required to comply with our current Privacy Notice. We reserve the right to change this Notice. Any revision will affect health information we already have about you as well as information we receive in the future. Any revisions to this notice will be posted in our offices and on our website and will be made available to you upon request. HOW WE WILL USE AND DISCLOSE YOUR HEALTH INFORMATION The following describes in general different ways we may use or disclose your health information. Treatment. We will use and disclosure your health information to provide and coordinate your health care and related services. Riverbend may disclose your health information among members of your treatment team or in programs in which you participate or to our emergency services clinicians. For example, our staff may discuss your care at a case conference. Payment. We may use or disclose your health information so that the services you receive are billed to, and payment is collected from you, your health plan or other third party. For example, we may disclose your health information to permit your health plan to approve payment for additional visits to your therapist. Operations. We may use and disclose health information about you as necessary to run our organization and make sure that clients receive quality care. For example, we may use or disclose your information to review the performance of our staff, train students, or develop new programs. We may combine health information of many of our consumers to decide whether new treatment approaches are effective. We may also combine health information that does not identify you with health information from other providers to compare how we are doing and see where we can make improvements. Reminders and Follow-up. We may use and disclose your health information to contact you to remind you of your appointments or to follow up with you about your care. Options. We may use or disclose your health information to inform you about treatment options or alternatives or health-related benefits or services that may be of interest to you. If you do not want us to provide you with such information, you must notify the Privacy Officer in writing. Fundraising. We may use or disclose your name, address or phone number to contact you about raising money for our programs. If you do not want us to contact you for this purpose, you must notify the Privacy Officer in writing. Business Associates. We may use or disclose your information to companies and professionals such as our accountants that assist us to run our organization. Contracts with these businesses assure that the privacy of your health information is protected. Individuals Involved in Your Care. We may provide health information about you to someone who pays for your care. In an emergency we may use or disclose your health information to notify a family member or other person responsible for your care of your location, general condition or death. We may also use or disclose your health information to an entity assisting in disaster relief to inform your family about your condition. Research. We may disclose your health information to researchers when you have agreed to participate in a study. We may also disclose your health information to researchers looking at medical records when adequate steps have been taken to protect the privacy of your health information and a committee for the protection of human subjects has approved the study. Disclosure Required By Law. We will disclose health information about you when required to do so by federal, state or local law such as a court order or search warrant, or a report of abuse, neglect or exploitation. Averting a Serious Threat to Health or Safety. We may use or disclose health information about you when necessary to prevent a serious threat to your health or safety or to the health or safety of others. For example, health information may be used or disclosed for an Involuntary Emergency Admission, to revoke a conditional discharge or to make a warning if you threaten others. Public Health Activities. We may disclose health information about you as necessary for public health activities. For example, we may make a report to prevent or control disease or to report the abuse or neglect of a child or the abuse, neglect or exploitation of a vulnerable adult. Health Oversight Activities. We may disclose health information about you to a state or federal health oversight agency for monitoring, licensing, auditing, inspection or investigation activities which are authorized by law. Law Enforcement Activities. We may disclose health information to a law enforcement official for law enforcement purposes when the information is needed to identify or locate a missing person; to report a death that may be the result of criminal conduct; or to report criminal conduct occurring on our premises. Medical Examiners or Funeral Directors. We may provide health information about our clients to a medical examiner to assist in identifying deceased persons and to determine the cause of death in certain circumstances. We may also disclose health information about our clients to funeral directors as necessary to carry out their duties. National Security. We may disclose medical information about you to authorized federal officials for intelligence and other national security activities authorized by Federal law. We may also disclose health information about you to authorized federal officials so they may conduct special investigations or protect the President or other authorized persons. Workers’ Compensation. We may disclose health information about you to comply with the state’s Workers’ Compensation Law. Law Enforcement Custody. If you are in the custody of a police officer or the House of Corrections, we may disclose health information about you, such as your medications or drug allergies, to ensure your safety and continuity of treatment. Other Uses or Disclosures you Authorize. Uses and disclosures not described in this Notice will generally only be made with your written permission, called an “authorization.” You have the right to revoke an authorization at any time. If you revoke your authorization we will not make any further uses or disclosures of your health information under that authorization, except to the extent that we have already taken an action you previously authorized. YOUR RIGHTS Right to Read and Copy. You may read or copy your health information including clinical and billing records and records from other providers included in Riverbend’s records. You may submit your request to a staff member or the Privacy Officer. If you request copies, we may charge a fee for the cost of copying. Right to Request Amendment. For as long as we keep records about you, you have the right to ask us to amend any health information used to make decisions about your care, including clinical and billing records. A request for amendment must be made in writing to Riverbend’s Privacy Officer indicating what information you believe to be incorrect and why. If we grant your request, we will annotate the health information in question. Under no circumstances will we remove or destroy original documents in your clinical record. We may deny your request if you ask us to amend health information that was not created by Riverbend, unless the person or entity that created the health information is no longer available to make the amendment; is not part of the health information we maintain to make decisions about your care; is not part of the health information that you would be permitted to inspect or copy; or is accurate and complete. Right to an Accounting. You have the right to request that we provide you with an accounting or list of disclosures we have made after April 14, 2003, excluding disclosures you authorized or which were for treatment, payment or healthcare operations. You may submit your request in writing on a form available from our Privacy Officer. The request should state the time period for which you wish to receive an accounting, but not be longer than six years. The first accounting requested within a twelve month period will be free. For additional requests during the year, we will charge you a fee. Right to Request Restrictions. You have the right to request a restriction on the health information we use or disclose about you for treatment, payment or health care operations. You may also ask that any part (or all) of your health information not be disclosed to family members or friends who may be involved in your care. You may request the restriction in writing to the Privacy Officer. We are not required to agree to a restriction that you may request. If we do agree, we will honor your request unless the restricted health information is needed to provide you with emergency treatment. Right to Alternative or Confidential Communications. We will normally communicate with you in person, by phone or by first class mail. We will accommodate all reasonable requests that we communicate with you only in a certain location or method. For example, you may request that we contact you only at work or by e-mail. You may request such manner of communication in writing to a staff member or the Privacy Officer. Right to a Paper Copy of this Notice. You can obtain a paper copy of this Notice of Privacy Practices at any time by contacting our Privacy Officer. Confidentiality of Substance Abuse Records. For individuals who have received treatment, diagnosis or referral treatment from our drug or alcohol abuse programs, the confidentiality of records of such programs is protected by Federal law and regulations. Retention of Protected Health Information. Riverbend retains client records for at least 7 years following the termination of services, unless the client was a minor during the time he/she received services in which case Riverbend retains records for at least 20 years following the client’s 18th birthday. Retained records may be kept in their original format or may be transferred and stored on electronic media. Following the expiration of the retention period Riverbend may absolutely destroy all files, notes, evaluations and other client data without further notice to the client. QUESTIONS, CONCERNS OR COMPLAINTS. If you have a question or believe your privacy rights have been violated you may request clarification or file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. Riverbend’s Privacy Officer will assist you with your complaint, if you request such assistance. We will not retaliate against you for filing a complaint.