Behavioral Health Wellness Clinic Intake

The Notice of Patient Privacy can also be viewed on our website: www.anthc.org/bhwc.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE READ AND REVIEW IT CAREFULLY.

This notice applies to services that are provided at the ANTHC Behavioral Health Wellness Clinic (BHWC), and the related records.

The ANTHC Behavioral Health Wellness Clinic (BHWC) respects your privacy and understands that your personal health information is a private and sensitive matter. We make a record of the care and services you receive at BHWC that is called “protected health information”, (PHI). This information is needed to give you quality health care and to comply with the law. For example, this information includes your symptoms, test results, diagnosis, treatment, health information from other health care providers, and billing and payment information related to those services. We will not disclose your information to others unless you authorize us to do so, or unless the law authorizes or requires us to do so.

This privacy notice will tell you about:
(1) the way that we may use and disclose PHI about you;
(2) your privacy rights;
(3) special rules for clients of BHWC’s alcohol and/or drug prevention and treatment programs; and
(4) BHWC’s responsibilities in using and disclosing your PHI.

HOW BHWC MAY USE & DISCLOSE YOUR HEALTH INFORMATION
The following is an explanation and example of some of the ways your health information may be used and disclosed:

TREATMENT
We may use and disclose your PHI for treatment purposes. PHI we obtain during your care, or which is disclosed to us from you or your other providers, will be recorded in your health record and used by our staff (providers, nurses, pharmacists, administrative assistants, etc.) to help us decide appropriate care. We may also share PHI with others outside of BHWC as necessary providing your care. For example, we might share medication information with a specialist that we refer you to, to avoid treatment that might cause a negative reaction.

PAYMENT
We may use your PHI for payment purposes. “Payment” includes the activities of BHWC to obtain payment or be reimbursed for the services we provide to you. For example, insurance companies may need information about services you received at BHWC in order to authorize payment. In addition, if someone else is responsible for your health care costs, we may disclose information to that person when we seek payment.

HEALTH CARE OPERATIONS
We may use your PHI for health care operations. “Health care operations” are certain administrative, financial, legal, and quality improvement activities necessary to run BHWC programs and make sure all clients receive quality care. For example, we may use health information about you to evaluate the performance of our staff, or to evaluate the services provided at BHWC.

ELECTRONIC HEALTH INFORMATION SYSTEMS
We utilize electronic health information systems, including an integrated multi-facility electronic health information systems with a client service communications network that permits providers involved in your care at other tribal health care facilities, and the Indian Health Service to access PHI accumulated about you at our facilities. Once PHI is entered into many of these electronic systems, it cannot be removed. Once a user is authorized to have access to your PHI contained in some of these systems, the user will continue to have such access until determined otherwise.

APPOINTMENT REMINDERS
Our staff may use and disclose PHI to contact you as a reminder that you have an appointment for treatment or health care at BHWC. The PHI we use or disclose for this purpose will be limited to what is necessary to remind you of the appointment.

INTERPRETERS
In order to provide you proper care and services, we may use the services of an interpreter. This may require the use or disclosure of your PHI to the interpreter.

OTHER TREATMENTS AND/OR HEALTH PRODUCTS
We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you, or about health-related products or services that may be of interest to you.

RESEARCH
Under certain circumstances, we may use and disclose PHI about you for research purposes, both with and without your permission. Before we disclose your PHI without your permission, we ensure that researchers meet specific requirements under HIPAA to ensure the protection of your PHI, and if appropriate, seek approval from authorized bodies that ensure the protection of human research subjects.

FUNERAL DIRECTORS/CORONERS/STATE MEDICAL EXAMINER
We will disclose PHI about you to funeral directors, coroners and the state medical examiner, consistent with applicable law to allow them to carry out their duties.

PUBLIC HEALTH RISKS
We may disclose PHI about you for public health activities that can include the following:
• Prevention or control of disease, injury or disability;
• Reports of births and deaths;
• Reports of abuse or neglect of children, elders and dependent adults;
• Reports of reactions or problems with medications or health products;
• Notifying people of product recalls related to their health care;
• Notifying a person that they may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• Notifying a government authority if we believe a client 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.

WORKERS’ COMPENSATION LAWS
We will disclose PHI when required by state law and/or when you have made a workers’ compensation claim that provides benefits for work-related injuries or illness.

CORRECTIONAL INSTITUTIONS
If you are in jail or prison, we may disclose your PHI to the Department of Corrections for your health and the health and safety of others.

LAW ENFORCEMENT
We may disclose your PHI to law enforcement for certain purposes, such as to report injuries caused by guns or knives, when suspected that criminal conduct occurred at BHWC, to locate you when you are the suspect of a crime, to avert a serious and imminent threat to health and safety, or when legally required to do so, such as when we receive a valid subpoena or court order.

TISSUE DONATION, ORGAN PROCUREMENT AND TRANSPLANT
We may disclose your PHI to organizations that handle organ procurement or tissue transplantation or to an organ donation bank, to help with organ or tissue donation and transplant if you or your family members agree to such disclosure in advance.

HEALTH AND SAFETY OVERSIGHT
We will disclose health care your PHI to a health oversight agency when required by law. These oversight activities include audits, investigations and medical licensure.

DISASTER RELIEF PURPOSES
We may disclose your PHI to disaster relief agencies or law enforcement to assist in notification of your condition to family or others in cases of disaster.

MILITARY AND VETERANS
If you are a member of the armed forces, BHWC may release your PHI as required by military command authorities.

COURT ORDERS, LAWSUITS AND DISPUTES
We may disclose health care information about you in response to a court or administrative order, subpoena, administrative request, or other legal process, in accordance with applicable law, including in cases where you are not a party to the dispute.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities as authorized by law.

BUSINESS ASSOCIATE AGREEMENTS
We may use your PHI and disclose it to individuals and organizations that assist BHWC with health care operations, including complying with its legal obligations. For example, BHWC may disclose PHI to consultants or attorneys who assist us in our business activities. These business associates must agree to protect the confidentiality of any PHI that they receive or have access to.

OTHER USES AND DISCLOSURES
We may also use and disclose your PHI to enhance health care services, to protect client safety, to safeguard public health, to ensure that our facilities and practitioners comply with government and accreditation standards and when otherwise allowed by law. For example:
1. We may use certain information about the care you received at BHWC to fundraise for the benefit of BHWC. If we engage in fundraising, you have the right to opt out of receiving such communications.
2. We provide information regarding FDA regulated drugs and devices to the U.S. Food and Drug Administration;
3. We provide government oversight agencies with data for health oversight activities such as auditing or licensure;
4. We provide notices to appropriate individuals when we believe it necessary to avoid a serious threat to health or safety or to prevent serious harm to an individual; and
5. We disclose information when otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining our compliance with our obligations to protect the privacy of your health information.

NOTIFICATION OF FAMILY AND OTHERS
Unless you object, we may release PHI about you to a friend or family member who is involved in your health care, or payment for your health care, while you are receiving services. In emergency cases where you are unavailable or incapacitated, or do not otherwise object, we may also tell your family or friends your location and general condition. If you would like to restrict the information provided to family or friends, please contact the appropriate number at the end of this notice.

BHWC DIRECTORY
If you are staying in the hospital, information may be provided to people who ask for you by name. We may use and disclose the following information in the hospital directory:
• Your name,
• Location,
• General condition, and
• Religion (only to clergy.)

You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

If you want a family member or friend to be able to access PHI about you or assist in arranging your health care, such as scheduling or checking on appointment times, please make sure that an authorization is on file for that person to access your records. This will be required for individuals to assist you in this manner.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other than the uses and disclosures described above, information will be used or disclosed only as allowed or required by law, or with your written authorization. Uses and disclosures such as the release of psychotherapy notes, uses for marketing and the sale of protected health information require your prior written authorization. If you provide us with written authorization, you have the right to revoke that authorization at any time unless the disclosure is required by law or in circumstances where we have otherwise relied on the authorization or the law prohibits revocation.

SPECIAL RULES FOR SUBSTANCE USE DISORDER CLIENT RECORDS
If you receive services at a substance use disorder (SUD) treatment program, whether at BHWC or another health care entity, your medical records that identify you as receiving those services may be protected not only by HIPAA, but also by 42 C.F.R. Part 2 (“Part 2”), regulations governing the confidentiality of SUD client records. Part 2 provides additional safeguards to protect the privacy of these records.

BHWC must obtain your written consent before disclosing records protected by Part 2 client, including before releasing information for payment purposes. BHWC may condition treatment on receiving your consent for payment purposes. Federal law does, however, permit BHWC to release records protected by Part 2 client in certain circumstances without your written authorization.

These are disclosures:
• Pursuant to an agreement between BHWC and a qualified service organization or business associate;
• For research, audit, or evaluation purposes;
• To report a crime against BHWC personnel or on BHWC property;
• To medical personnel in a bona fide medical emergency;
• To report suspected child abuse or neglect to appropriate authorities;
• Pursuant to a court order.

YOUR INDIVIDUAL RIGHTS REGARDING YOUR HEALTH INFORMATION
You have specific individual rights as to the uses and disclosures of your PHI. The health and billing records we make and store belong to BHWC. The PHI in those records, however, generally belongs to you. You have the following rights:

QUESTIONS
You have the right to ask questions about any information contained in this notice.

NOTICE
You have the right to receive a copy of this Notice of Privacy Practices.

RIGHT TO REQUEST RESTRICTIONS ON USE
You have the right to ask BHWC to limit certain uses and disclosures. To request any limitation, you must submit your request to us in writing. We are not required or permitted to grant all such requests, but will honor requests where required or reasonably practicable, and shall inform you of our decision regarding your request. We will also honor request to restrict disclosures of PHI to an insurer for services paid for entirely out of pocket.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You may request that BHWC communicate with or contact you by a particular means (mail, e-mail, fax, etc.) or at a particular location, including for disclosing copies of your PHI. These requests must be made in writing and we have a form available for this type of request. BHWC will accommodate reasonable requests.

RIGHT TO REQUEST INSPECT AND RECEIVE COPIES
You may request to see and get a copy of your PHI. If your PHI is in electronic format, you may request that your copy also be in electronic format.

RIGHT TO REQUEST AN AMENDMENT TO YOUR RECORD
You have the right to request amendment of your PHI, which must be submitted to us in writing. We may accept your request and if we do, we will add an amendment to your record. If we deny your request, you may submit a written statement of disagreement with BHWC’s decision, that BHWC will include as part of your record. Please note that we may add our own statement disagreeing with your proposed changes to your record. Statements regarding changes in your health record may be included with any release of your records.

REVOKE OR CANCEL PRIOR AUTHORIZATIONS
If you authorized us to use or disclose your PHI, you may revoke your authorization in writing at any time. Once revoked, we will no longer use or disclose your PHI for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission, and if the authorization was obtained as a condition of obtaining insurance coverage or workers’ compensation coverage, applicable law may prohibit you from revoking authorization. other law provides the insurer with the right to contest a claim under the policy or the policy itself.

RIGHT TO KNOW ABOUT DISCLOSURES
You have the right to request a list (“an accounting”) of certain disclosures of your PHI outside of treatment, payment and operations. This list will not include disclosures to third party payers. You may request an accounting at any time. BHWC is only required by law to provide one accounting without charge during any 12-month period. We will notify you of the cost involved if you request this information more than once in a 12 month period. In some cases, we may be delayed in providing you a list of certain disclosures if required by law to not disclose. The list of disclosures will go back prior to the date requested a period of six years for paper records, and three years prior for electronic health records.

RIGHT TO BE NOTIFIED OF A BREACH
In the event of a breach of the privacy or security of your PHI, BHWC will notify you regarding the circumstances of the breach, efforts that BHWC has taken to correct or mitigate the breach, and steps you can take to protect yourself from potential harm.

NO RIGHT TO CERTAIN INFORMATION
There is certain information to which you do not have a right to access. Specifically, you do not have a right to access psychotherapy notes regarding your care, any information prepared in anticipation of a legal proceeding, or any information that might have other legal restrictions against disclosure. If BHWC refuses to give you access to certain information, you may request that BHWC provide you with information on your appeal rights, if any.

WHO WILL FOLLOW THIS NOTICE
• Any individuals authorized by BHWC to enter information into your health record;
• All BHWC departments and programs;
• Any member of a volunteer group we allow to help you while you are receiving services at BHWC;
• All individuals who are considered members of BHWCs workforce.

BHWC’s RESPONSIBILITIES
We are required by law to:
• Keep your protected health information private;
• Provide notice of our legal duties and privacy practices with respect to protected health information;
• Notify affected individuals following a breach of unsecured protected health information;
• Give you this Notice of Privacy Practices; and
• Follow the terms of the Notice of Privacy Practices currently in effect.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling or visiting any of our programs and asking for it or by visiting our website: https://www.anthc.org/conflict-of-interest/.

TO ASK FOR HELP, EXPRESS A CONCERN OR FILE A COMPLAINT
If you have questions, want more information, or want to report a problem about the handling of your health information, you may contact the BHWC Client Hotline at: 1-877-837-4251
If you believe your privacy rights were violated, you may file a written complaint to:

Alaska Native Tribal Health Consortium
c/o Ethics and Compliance Services
4315 Diplomacy Dr.
Anchorage, AK 99508

For general PHI, you can also file a complaint with the U.S. Secretary of the Department of Health and Human Services.

Violation of the protections established by 42 C.F.R. Part 2 for SUD client records is a crime. You have the right to file a complaint regarding a violation with the U.S. Attorney’s Office in Anchorage, reachable by mail at 222 West 7th Ave., Room 253 #9, Anchorage, AK 99513, or by phone at (907) 271-5071.

Please contact BHWC if you would like information on how to file with either governmental entity.
There will be no retaliation for filing a complaint.
Notice Effective Date: April 24, 2003 – revised July 15, 2013

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Effective Date: April 24, 2003 – revised July 15, 2013
The ANTHC Behavioral Health Wellness Clinic Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review the notice before signing this acknowledgment. As stated in the notice, the terms of the notice may change. If the notice is changed, you may obtain a revised copy by contacting the Compliance Department or asking any BHWC staff.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction except in special circumstances, but if we do, we are bound by our agreement.
You have the right to request a list of certain disclosures we have made of your protected health information.

By signing this form, you acknowledge receipt of BHWCs Notice of Privacy Practices.

I understand that by coming to see a provider at ANTHC and by cooperating with the requests and directions of its providers and staff, I am consenting to the care they provide unless I specifically object or otherwise decline one or more aspects of the care they offer. I understand that ANTHC has a right to bill my insurer and any other third party who may be obliged to cover the costs of the services I receive, and that federal Privacy law permits ANTHC to release certain health information to those insurers I have identified as being responsible for payment. I hereby assign my rights to such claims to ANTHC along with any benefits that I would otherwise be payable to me. I also agree to assist ANTHC pursue these claims and hereby authorize ANTHC to release medical information and take other steps that may be reasonable necessary to do so.