Notice of Privacy

NOTICE OF PRIVACY PRACTICES HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

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.

Introduction
We at Social Clubhouse understand that health information about you and the care you receive is personal. We are committed to and are required by law to maintain the privacy of your health information. This notice applies to all records of your care maintained by us and we will abide by the terms of this Notice for as long as it is in effect.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights.

How We Will Use and Disclose Your Health Information
We will use and disclose your health information as described in each category listed below. We will provide a general explanation of each category; however, this is not meant to describe all specific uses or disclosures of health information.

1. Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object
   1. Treatment
      We may use your health information to provide you with medical treatment or services. We may disclose information about you to physicians, nurses, technicians, health care trainees, or other personnel who are involved in caring for you. For example, our psychiatrist may consider your blood pressure before prescribing certain medications for you. Different departments within Social Clubhouse may share medical information about you to coordinate care at treatment team meetings.
   2. Payment
      We may use and disclose health information about you so treatment and services you receive may be billed and payment collected from you, an insurance company or a third party involved in the payment of your medical bills. For example, we may disclose protected health information to your insurer or the third party responsible for payment of your care for the following activities: making a determination of eligibility or coverage for health insurance; reviewing your services to determine if they were medically necessary, which may include copies or excerpts of your medical records; reviewing your services to determine if they were appropriately authorized or certified in advance of your care; reviewing your services for purposes of utilization review (to ensure the appropriateness of your care).
   3. Health Care Operations
      We may use and disclose health information about you for health care operations. Your health information may be used and disclosed for activities including quality assurance, utilization review, medical review, internal auditing, accreditation, social services certification, licensing or credentialing activities, medical research, and education purposes. These disclosures are necessary to run the organization and make sure that all consumers receive quality care. For example, we may use health information to review our treatment and services and to evaluate performance of staff. We may also disclose information to physicians, nurses, technicians, medical students, and other personnel for review and learning purposes.
   4. Appointment Reminders
      We may use and disclose limited health information (such as your name, address, and telephone number) to contact you as a reminder that you have an appointment for treatment or medical care.
   5. Treatment Alternatives
      We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
   6. Health Related Benefits and Services
      We may use or disclose health information to tell you about health-related benefits or services that may be of interest to you.
   7. To Another Health Care Provider
      We may use or disclose health information about you to another health care provider that may treat you and/or receive payment for services provided to you. For example, we may share your health information with a hospital where you will be receiving treatment.
   8. Business Associates
      We may use or disclose information about you to entities assisting us in providing services related to treatment, payment, or health care operations. We are required to have a Business Associate Contract in place with all entities with which we will share your protected health information.
   9. De-Identified Data/Limited Data Sets
      We may use or disclose health information about you if we remove all information that could be used to identify you (what is known as “de-identified” information). We may also use or disclose a limited amount of health information about you (a “limited data set”) for the purposes of research, public health, or health care operations if we enter into a data use agreement with the recipient of the data.
   10. Emergencies
       We may use and disclose your health information in an emergency treatment situation. For example, we may provide your health information to a paramedic who is transporting you in an ambulance.
   11. Research
       We may disclose your health information to researchers when their research has been approved by an Institutional Review Board or a similar privacy board that has waived the individual authorization requirement in accordance with the regulations covering this area.
   12. As Required by Law
       We will disclose health information about you when required to do so by federal or state law.
   13. To Avert Serious Threat to Health or Safety
       We may use and disclose health information about you to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person.
   14. Organ and Tissue Donation
       If you are an organ donor, we may use or disclose your health information to an organ procurement organization or to an entity that conducts organ, eye or tissue transplantation, or serves as an organ donation bank, as necessary to facilitate organ, eye or tissue donation and transplantation.
   15. Public Health Risk
       We may disclose your health information for public health activities involved in preventing or controlling disease, injury, or disability. For example, we are required by state law to report the existence of communicable disease, such as acquired immune deficiency syndrome (“AIDS”), to the New Jersey State Department of Health and Senior Services to protect the health and wellbeing of the public. Other activities disclosed include the following:
       • To prevent or control disease, injury, or disability;
       • To report births and deaths;
       • To report child abuse and neglect;
       • To report reactions to medication or problems with products;
       • To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading of a disease or condition;
       • To notify the appropriate governmental authority if we believe a consumer has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
   16. Health Oversight Activities
       We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights.
   17. Law Enforcement
       We may release medical information if asked to do so by a law enforcement official:
       • In response to a court order;
       • To identify or locate a suspect, fugitive, material witness, or missing person;
       • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
       • About a death we believe may be the result of criminal conduct;
       • About criminal conduct at our facility;
       • In emergency circumstances to report a crime; the location of a crime or victims; or identity, description or location of the person who committed the crime.
   18. Coroners, Medical Examiners and Funeral Directors
       We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about consumers to funeral directors as necessary to carry out duties.
   19. Disclosures in Legal Proceedings
       We may disclose health information about you to a court or administrative agency when a judge or administrative agency orders us to do so.
   20. Military and Veterans
       If you are a member of the armed forces, we may disclose your health information as required by military command authorities. We may also disclose your health information to determine your eligibility for benefits provided by the Department of Veterans Affairs. If you are a member of a foreign military service, we may disclose your health information to that foreign military authority.
   21. National Security and Protective Services for the President and Others
       We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may also disclose health information about you to authorized federal officials, so they may provide protection to the President, other authorized persons, or foreign heads of state or, so they may conduct special investigations.
   22. Inmates
       If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official.
   23. Workers’ Compensation
       We may disclose health information about you to comply with the state’s Workers’ Compensation Law.
   24. Employers
       We may disclose health information about you to your employer if your health care is part of an evaluation relating to medical surveillance of the workplace, or to evaluate whether you have a work- related illness or
2. Uses and Disclosures That May Be Made Without Your Authorization, But For Which You Will Have An Opportunity To Object
   1. Facility Directory
      It is the policy of Social Clubhouse Behavioral Health not to provide confirmation of names of consumers being treated by our facilities except to persons involved in your care (see below).
   2. Persons Involved In Your Care
      Unless you object, we may release health information about you to someone, including a family member, legal guardian, or caregiver, who is involved in your medical care or payment of your medical care.
   3. Disaster Relief
      Unless you object, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
3. Uses and Disclosures of Your Health Information With Your Written Authorization
   Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission, called an “authorization”. 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 health information about you. You understand that we are unable to take back any records of the medical care that we have provided to you.
4. Your Rights Regarding Your Health Information
   1. Right to Inspect and Copy
      You have the right to request an opportunity to inspect or obtain a copy of health information in our possession. Usually, this will include clinical and billing records. You must submit your request in writing. If you request a copy of the information, we may charge a fee for the cost of copying, mailing, and supplies associated with complying with your request.

      We may deny your request to inspect or obtain a copy of your health information in certain limited circumstances. In some cases, you will have the right to have the denial reviewed by another health care professional chosen by us and who was not directly included in the original decision to deny access. If you are denied access, we will inform you in writing if the denial of your request may be reviewed. If it is reviewable and you request a review in writing, when the review is completed, we will comply with the outcome of the review.

   2. Right to Amend
      For as long as we keep records about you, you have the right to request us to amend any health information used to make decisions about your care or payment for your care. To request an amendment, your request must be in writing, and must explain why you believe the information is incorrect or inaccurate.

      We may deny your request under certain circumstances. If we deny your request to amend, we will send you a written notice of the denial stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with the denial. If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request.

      If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as the original request) to all future disclosures of the health information that is the subject of your request.

   3. Right to an Accounting of Disclosures
      You have the right to request that we provide you with an accounting of list of disclosures we have made of your health information. This list will not include disclosures of your health information made for treatment, payment, or health care operations, made to you, or made as a result of an authorization signed by you.

      To request an accounting of disclosures, you must submit your request in writing. The request should state the time period for which you wish to receive an accounting. This time period should not be longer than six (6) years and not included dates before April 14, 2003

      The first accounting you request within a twelve (12) month period will be free. For additional requests during the same twelve (12) month period, we will charge you for costs of the accounting. We will notify you of the amount we will charge, and you may choose to withdraw or modify your request before we incur any costs.

   4. Right to Request Restrictions
      You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must inform us at a time of registration or in writing.
   5. Right to Request Confidential Communications
      You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at a specified telephone number. To request confidential communications, you must notify us at the time of registration or in writing.

      We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

   6. Right to a Paper Copy of This Notice
      You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.
5. Complaints
   If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services. To file a complaint with us, contact the Director of Substance Abuse Counseling Services, Social Clubhouse 58 Brown Avenue, Springfield, New Jersey, 07018.
6. Changes to This Notice
   We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at all of our locations where we provide care. You may obtain a copy of our Current Notice of Privacy Practices by requesting a copy be sent to you, or by asking for one any time you are at our office.
7. Who Will Follow This Notice
   This Notice of Privacy Practices will be followed by all of Social Clubhouse Behavioral Health staff.

Social Clubhouse abides by Federal Health Insurance Portability and Accountability Act 1 196 (HIPAA) of 1996. The counselor / staff has explained the above summary to me and has answered all my concerns regarding this program policy in a satisfactory manner. My signature below states that I understand and agree to the practice and consider myself informed. I understand that I can ask for a copy of this summary.