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.
Each time you
receive service from the MH/MR Program a record of the service you received is
made. Typically, this record contains any requests for services you have and
case management service provided to meet your requests. This information may
contain some of your personal case management information. The information, often referred to as your
case management record, serves as a:
·
basis for planning your service
·
means of communication among the human service
professionals who contribute to your care
·
legal documentation of the care you received
·
means by which you or a third-party payer can verify
that services billed were actually provided
·
source of information for public health officials and
the Pennsylvania Department of Public Welfare who oversee the delivery of
health care in
·
quality improvement tool with which we can assess and
continually work to improve the care we render and the outcomes we achieve
Understanding
what is in your record and how your case management information is used helps
you to: ensure its accuracy; better understand who, what, when, where, and why
others may access your case management information; and make more informed
decisions when authorizing disclosure to others.
Our
Responsibilities
The MH/MR Program is required to:
·
maintain the privacy of your case management
information
·
provide you with this Notice as to our legal duties
and privacy practices with respect to information we collect and maintain about
you
·
abide by the terms of this Notice
·
notify you if we are unable to agree to a requested
restriction
·
accommodate
reasonable requests you may have to communicate case management information by
alternative means or at alternative locations.
·
Maintain your record for seven years after discharge
from MH/MR Program services.
We reserve
the right to change our practices and to make the new provisions effective for
all protected case management information we maintain. Should our information
practices change, we will mail you a revised notice.
We will not use or disclose your case management information without
your authorization, except as described in this Notice.
(1)
Service Planning. We will use your case management information
for service planning. For example, information obtained by a case manager, or
other member of your case management service team will be recorded in your
record and used to determine the supports and services you choose to utilize.
Your case manager or other professional will document in your record his or her
expectations of the members of your service team. Members of your case management service team
will monitor progress and determine your satisfaction with the services and
supports. In that way your case manager will know how you are responding to a
service. With your consent we will also provide other professionals helping you
or a subsequent professional with copies of various reports that should assist
him or her in serving you once you are discharged from our MH/MR Program.
(2)
Payment.
When there is a charge for service and with your consent, we will use
your case management information for payment from the third party payor you designate, including Medicare and Medicaid. The
information on or accompanying the bill will be limited to that information
necessary to establish the claims for which reimbursement is sought. For example, the bill may include information
of the dates, types and costs services, and a general description of the
general purpose of each service.
(3)
Quality Assurance. We will use your case
management information in an effort to continually improve the quality and
effectiveness of the service we provide.
(4)
Notification.
With your written consent, or without your consent in a crisis
situation, we may use or disclose information to notify or assist in notifying
a family member, personal representative, or another person responsible for
your care, of your location, and general condition.
(5)
Communication with family. With your consent, we may disclose to a
family member, other relative, close personal friend or any other person you
identify, case management information relevant to that person's involvement in
your care or payment related to your service.
(6)
Case Management Operations. Case
management services include the following activities: assessment of needs,
service planning, referral to services, problem solving, monitoring of service,
advocacy and discharge planning. To accomplish the goals of case management,
case managers will contact providers of service, family members, and other
significant people in the lives of the person being served on an ongoing basis. Case managers will make contact by the use of
the telephone, mail, facsimile, and in person. Except in a crisis situation,
your prior written permission to make these contacts is obtained.
(7)
Commitment Proceedings. During the course of an involuntary
commitment proceeding, the court may direct that it or a mental health review
officer, as allowed under the Mental Health Procedures Act have access without
your consent to your personal health information for purposes of conducting the
hearing. Also without your consent,
information may be disclosed to attorneys assigned to represent you if you are
the subject of an involuntary commitment proceeding. Act 77, approved
(8)
Public health. As required by law, we may
be required to disclose your case management information without your consent
to public health or legal authorities charged with preventing or controlling
disease, injury, or disability.
(9)
Correctional institution. Should
you be an inmate of a correctional institution, or state mental hospital we may
be required to disclose to the health care professionals at the institution,
without your consent, case management information necessary for your treatment.
(10)
Crisis Situation. Without your consent we
may release information in response to crisis or an emergency medical situation
when release of information is necessary to prevent serious risk of bodily harm
or death. Only specific information
pertinent to the relief of the emergency may be released on a nonconsensual
basis. Program staff
have the responsibility to warn a third party when a specific threat has
been made against that person without the consent of the person making the
treat.
(11)
Reporting of Child Abuse and Geriatric Abuse. Program staff are
required by law to report a person who is suspected of child abuse and abuse of
a person over the age of 60 to State authorities without the consent of the
individual suspected of committing the abuse.
(12)
In response to a court order. Your case management information may be
released without your consent in response to a court order, when production of
the documents is ordered by a court.
Although
your record is the physical property of the MH/MR Program, the information in
your record belongs to you. You have the following rights regarding your
record:
·
You may request that we not use or disclose your case
management information for a particular reason related to treatment, payment,
or general health care operations, and/or to a personal representative or
guardian. We ask that such requests be made in writing. Although we will
consider your request, please be aware that we are under no obligation to
accept it or to abide by it.
·
If you are dissatisfied with the manner in which or
the location where you are receiving communications from us that are related to
your case management information, you may request that we provide you with such
information by alternative means or at alternative locations. Such a request
must be made in writing, and submitted to your case manager or his or her
supervisor.
·
You may request to inspect and/or obtain copies of
case management information we have about you, which will be provided to you up
to seven years after your discharge from service. If you request copies we may
charge you a reasonable fee for retrieval and copying costs.
·
If you believe that any case management information
in your record is incorrect or if you believe that important information is
missing, you may request that we correct the existing information or add the missing
information. Such requests must be made in writing, and must provide a reason
to support the request. We ask that you use the form provided by the MH/MR
Program to make such requests. For a request form, please contact your case
manager or the Medical Records Department at 814-265-1060 ext 300 or
814-765-1820 ext 300.
·
You may request that we provide you with a written
accounting of all disclosures made by us during the time period for which you
request (not to exceed 6 years). We ask that such requests be made in writing
on a form provided by the MH/MR Program. Please note that an accounting will
not apply to any of the following types of disclosures: disclosures made for
reasons of treatment, payment or health care operations; disclosures made to you
or your legal representative, or any other individual involved with your care;
disclosures to correctional institutions or law enforcement officials; and
disclosures for national security purposes. You will not be charged for your
first accounting request in any 12-month period. However, for any requests that
you make thereafter, you may be charged a reasonable, cost-based fee.
·
You have the right to obtain a paper copy of this
Notice of Information Practices upon request.
·
You may revoke an authorization to use or disclose
case management information, except to the extent that action has already been
taken. Such a request must be made in writing.
If have
questions and would like additional information, you may contact our
facility/agency's
If you believe
that your privacy rights have been violated, you may file a complaint with us.
These complaints must be filed in writing on a form provided by the MH/MR
Program. The complaint form may be obtained from your case manager or the
Medical Records Department by calling 814-265-1060 ext 300 or 814-765-1820 ext
300 and when completed should be returned to the
Effective
Date: