NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Synergy Recovery Center, LLC must maintain the privacy of your personal health information and give you this notice that describes our legal duties and privacy practices concerning your personal health information. Usually, when we release health information we must release only the minimum necessary information to achieve the purpose of the use or disclosure. However, all of your personal health information that you designate will be available for release if you sign an authorization form, if you request the information for yourself, to a provider regarding your treatment, or due to a legal requirement. Synergy Recovery Center, LLC must follow the privacy practices described in this notice.
We reserve the right to change the privacy practices described in this notice. Changes to our privacy practices apply to all health information we maintain. If there is a change in our privacy practices we will send you a revised copy.
WITHOUT YOUR WRITTEN AUTHORIZATION we are allowed to use your health information for the following purposes:
- TREATMENT: For example, we may use the information in your physician’s orders to administer your medication or support you with your diet. We may use information to design your treatment plan.
- PAYMENT: In order to receive payment for services we provide we must submit a bill that identifies you, your services and the treatment provided. If we are billing an insurance company for counseling services we must give a diagnosis code.
- HEALTH CARE OPERATIONS: We may need your treatment and outcome information to improve the quality of our services or the cost of care we deliver. We will also evaluate the performance of your support staff as they administer medications or support you in other ways.
- AS REQUIRED OR PERMITTED BY LAW: We may need to report some of your health information to legal authorities, such as law enforcement officials, courts or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries or we may have to respond to a court order.
- HEALTH OVERSIGHT ACTIVITIES: It is permitted to disclose health information so monitoring agencies can investigate, inspect, accredit, license, and discipline those who work in the healthcare system.
- PUBLIC HEALTH: We are required to report health information to help prevent or control disease, injury or disability. Examples may include reporting of certain diseases, injuries, birth or death information, information needed by the Food and Drug Administration or information related to child abuse or neglect. It may also be necessary to report certain work-related illnesses and injuries to keep the workplace safe.
- CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS: We must report health information in the case of death so these individuals can carry out their duties such as identifying the body, determining cause of death or bury the dead.
- ORGAN, EYE OR TISSUE DONATION: We must release health information related to these items.
- RESEARCH: With special permission and under certain circumstances we may use and disclose health information to help conduct research. For example we may do research to see if our treatment procedures are effective and meet our outcomes.
- TO AVOID A SERIOUS THREAT TO HEALTH OR SAFETY: We may, as required by law, release health information to the proper authorities if we believe, in good faith, that this release is necessary to prevent or minimize a serious and upcoming threat to your or the public’s health and safety.
- FOR NATIONAL SECURITY, MILITARY OR INCARCERATION/LAW ENFORCEMENT CUSTODY: If you are involved with national security, the military or intelligence activities or in the custody of law enforcement officials, or an inmate of a penal institution, we may release health information to the proper authorities so they may carry out their duties according to the law.
- WORKER’S COMPENSATION: We must disclose health information to the appropriate persons to comply with the laws related to worker’s compensation or disability programs.
- THOSE INVOLVED WITH YOUR CARE OR PAYMENT OF YOUR CARE: If people such as your family, your close personal friends, are helping care for you or pay your medical bills, we may release important health information about you to those people. The information released may include your general condition or your death. You have the right to object to such disclosure, unless you are unable to function or there is an emergency. We may also release health information to organizations authorized to handle disaster relief efforts so those who care for you can receive information about your location or health status. We will allow you to agree or disagree verbally to such release, unless there is an emergency. It is our duty to give you enough information so you can decide whether or not to object to release of your health information to others involved with your care.
WITH THE EXCEPTION OF THE SITUATIONS DESCRIBED ABOVE WE MUST OBTAIN YOUR SPECIFIC WRITTEN AUTHORIZATION FOR ANY OTHER RELEASE OF YOUR HEALTH INFORMATION.
If you sign an authorization, you may withdraw this authorization at any time, in writing as described on the form. If you wish to withdraw your authorization, submit your written request to Paige Tuck, 3955 S. Farm Road 223, Rogersville, MO 65742.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
You have the right to:
- Inspect and copy your health information. You may request that you inspect and obtain a copy of your health information. This does not apply to psychotherapy notes or information gathered for judicial proceedings, for example. We may charge you a nonrefundable fee if you want a copy of your health information.
- Ask that your health information be amended or corrected. If you believe the health information we maintain on you is not correct, you may ask us to correct it. You must ask in writing and give a reason why it should be changed. If we did not create this information, if we disagree with the correction we may deny your request.
- Obtain a record of disclosures of your health information. You may ask for a list of disclosures of protected healthcare information made after August 17, 2015. We will give you a list within 60 days unless there is a reason to ask for a 30 day extension. This list will not include disclosures made to you, for treatment, payment or health care operations, for national security, law enforcement and health care oversight activities. The list will include other disclosures and include the date of the disclosure, a description of the information disclosed, who received the information and the purpose of the disclosure. The first list in a given year will be free but subsequent lists in the same year may require a fee.
- Ask for restriction on certain uses and disclosures. You may ask for restrictions about how your health information is used or to whom it is disclosed, even if the restriction affects your treatment, our payment or health care operations. You may request restrictions on health information provided to family or friends involved in your care or payment of medical bills or to disaster relief agencies. We are not required to agree to all restrictions.
- Ask to receive health information in different and protected ways. For example, you could ask to discuss health information in a room away from all other people or ask for information to be sent in a letter.
- Receive a paper copy of this notice.
- If you believe your privacy rights have been violated you may complain both to us and to the Secretary of Health and Human Services.
Filing a Grievance/Request for Change
Synergy Recovery Center, LLC. offers all clients the opportunity to discuss incidents in which the client believes a violation of their civil rights has occurred. In the event of a grievance of this type or if a client wishes to submit a suggestion to improve program functioning, the client should contact the Clinical Director, Ann Koetting, through a “Grievance or Request for Change” form. The Clinical Director may respond within 48 hours to confirm receipt of the request. The Clinical Director will determine an appropriate resolution and present the response to the client within 7 days.
Ann Koetting, Clinical Director
Synergy Recovery Center, LLC
3955 S. Farm Rd. 223
Rogersville, MO 65742
If the client is still unsatisfied, then she may file an appeal by letter to the appropriate agency within ten (10) calendar days of receiving word from the Clinical Director. The letter should be addressed to:
Treatment Coordinator, Southwest Region Client Rights Monitor
Division of Alcohol and Drug Abuse or Missouri Dept of Mental Health
149 Park Central Square, Suite 910 PO Box 687
Springfield, MO 65806 Jefferson City, MO 65102
800-364-9687 DMH
800-575-7480 ADA
Missouri Department of Mental Health
Clients Rights and Privileges
You shall be entitled to the following without limitation:
- Visits from your lawyer, doctor, or clergyman at reasonable times
- Correspondence by sealed mail with officials of the Department of Mental Health, your lawyer, or a court
- To receive humane care and treatment
- To medical care and treatment in accordance with the highest standards acceptable in medical practice to the extent that the facilities, equipment and personnel are available
- Safe and clean housing
- To attend religious services
- Prompt evaluation, care and treatment, habilitation or rehabilitation and explanation of said treatments
- To be treated with respect and dignity as a human being
- To be a subject of an early experiment only with your consent or the consent of the person legally authorized to act for you
- To have your private doctor examine you at your own expense
- To be evaluated and cared for in the least restrictive place
- To refuse hazardous treatment or surgery unless ordered by a court
- To request and have a second opinion before hazardous treatment or irreversible surgery is performed, except in emergencies
- Nourishing and well balanced meals
- To not work, unless as part of your treatment, habilitation, or rehabilitation
- To be free from any form of abuse or neglect
- Records kept confidential
Unless otherwise stated by law, you have the same legal rights and responsibilities as any other citizen and this facility cannot deny admission or services to you because of your race, sex, creed, marital status, national origin, disability or age.
The following rights and privileges may be limited if necessary, as documented in your record:
- Wearing of your own clothes and use of your own personal things
- To keep some spending money for small purchases
- To send and receive mail
- To have visitors at reasonable hours
- To use the telephone at reasonable hours
- To view your records
- To have physical exercise and outdoor recreation
- To have access to current newspapers, magazines, and radio and television programming
- To be free from chemical or physical restraint, seclusion or isolation
Statement of Confidentiality
This form is to be completed by individuals not employed by Synergy Recovery Center, LLC. who may observe or review PHI either created by or provided to Synergy Recovery Center, LLC. for treatment and service purposes. I have been granted access to enter facilities maintained by Synergy Recovery Center, LLC. as a client receiving services rendered at their treatment home located at 3955 S. Farm Rd. 223, Rogersville, MO 65742. I understand this access has been granted to me in limited capacity for the primary purpose of treatment participation and that I may be exposed to protected information of other persons served during treatment participation.
I agree to keep confidential any and all information shared among persons served (clients) including but not limited to disclosures revealed during Group Education sessions, Group Counseling sessions, other structured activities sponsored/supervised by Synergy Recovery Center, LLC. and/or during participation in communal living in the treatment home. I will not disclose any names, other identifying information, or explicit details to any individuals about persons served in any programs administered by Synergy Recovery Center, LLC. .
I understand that all information I may acquire is privileged information protected under 45 CFR Parts 160 and 164. Unauthorized use or disclosure is strictly prohibited and may result in both civil and criminal penalties for wrongful disclosure.
I acknowledge that by signing below, I pledge to protect the information and identities shared by other persons at all times and to ensure that it remains confidential. I understand that unauthorized release of Protected Health Information may result in civil and criminal penalties up to and including $250,000 fines and prison terms.
I understand that Synergy Recovery Center, LLC. will initiate or cooperate with investigations concerning confidentiality breaches and may present this signed agreement for review during such investigations.
