Notice of Privacy Practices
Kaci Sapinski, Executive Director New Vision Wilderness (715)748-0251
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the health care and services you receive at this office. Your health information may include information created and received by this office, may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose health information for the following purposes:
We may use health information about you to provide you with clinical treatment or services. We may disclose health information about you to doctors, nurses, therapists, wilderness guides, technicians, office staff or other persons involved in taking care of individuals who go out on the expedition and the related health information of those who participate in the family meetings before and after the wilderness expeditions which are an integral part of the treatment.
For example, expedition therapists treating an adolescent for a chemical dependency problem will need to know other
medical information such as whether you have been treated for any medical or mental health conditions and whether any medications are being taken. Expeditionstaffmayneedtocontactaconsultingdoctorofyourstodeterminethedegreeof risk associated with a condition or use of medications during an expedition.
Different personnel in our office or in the field may share information about you and disclose information to people who do not work for NVW in order to coordinate your care, such as securing prescriptions prior to going out on expedition, or scheduling a physical prior to departure. While you are out on expedition staff will be in contact with your parents or others who have responsibility and care about you. Updates about your progress that may include health information will be shared with them at that time as part of the treatment program. Other health care providers outside of this office may be part of your clinical care and may require information about you that we give to them in order to provide for continuity of treatment.
We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or other third party.
For example, we may need to give your health plan health information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will pay for treatment.
For “Health Care Operations”:
We may use and disclose health information about you in order to run the office and make sure that you and our other patients receive quality care.
For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or clinical care at the office.
Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health Related Products and Services: We may tell you about health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing (at the address at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
Ordinarily for situations involving Treatment, Payment, and Operations (T/P/O) described above, or contacting you directly, your consent is not required each time we release health information. Whenever alcohol or substance abuse informationmaybeinvolvedFederalandStateLawrequiresaspecificwrittenAuthorization. In order to simplify paperwork and give everyone the same privacy rights, all students and their parents or responsible caregivers will be asked to Authorize treatment, even if they do not have a substance abuse problem. The Authorization will specify who is to receive the information, the purpose of the release of information, and a time period after which the Authorization will terminate. YoumaymodifyorrevokeanAuthorizationatanytime.However,ifweareunabletofulfillourrequirements related to T/P/O, we may choose to discontinue providing you with health care treatment and services until the Authorization is provided to us.
We may use or disclose health information about you for the following purposes, subject to all applicable legal requirement and limitations:
To Avert a Serious Threat to Health or Safety:
We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law:
We will disclose health information about you when required to do so by Federal, State or local law.
We may use and disclose health information about you for research projects that are subject to a separate specific written Authorization. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be contacting you after your treatment at NVW is completed.
Military, Veterans, National Security and Intelligence:
If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
We may release health information about you for workers’ compensation or similar programs, but not when an issue of substance abuse is a focus of treatment without your written Authorization to specifically release health information to the workers’compensationcarrier. Theseprogramsprovidebenefitsforwork-relatedinjuriesorillness.
Public Health Risks:
We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability: or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities:
We may disclose health information to a health oversight agency for audits, investigations, inspections or licensing purposes. ThesedisclosuresmaybenecessaryforcertainStateandFederalagenciestomonitorthehealthcaresystem, government programs, and compliance with civil rights laws.
Lawsuits and Disputes:
I f you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrativeorder. Subjecttoallapplicablelegalrequirements,wemayalsodisclosehealthinformationaboutyouin response to a subpoena.
We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Information Not Personally Identifiable:
We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends:
We may disclose health information about you to your family members or friends, covered broadly under your written Authorization, but on an issue by issue basis if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For
example, we may assume you agree to our disclosure of your personal health information to your parents when they participate with you in the expedition experience and group family meetings, or with staff during your absence on the expedition.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. Forexample,wemayinformthepersonwhoaccompaniedyoutotheexpeditionandprovideupdatesonyour progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up filled prescriptions or medical supplies.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about
you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
In some instances, we may need specific, written Authorization from you in order to disclose certain types of specially- protected information such as HIV, substance abuse, psychotherapy notes, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy:
You have the right to inspect and copy your health information, such as clinical and billing records, that we keep and use to make decisions about your care. You must submit a written request to the Privacy Officer listed at the top of this document in order to inspect and/or copy records of your health information. If you request a copy, we may charge a fee for the costs of copying, mailing or other associated supplies. We have an initial period of 30 days to consider and process your request.
We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied copies of or access to health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend:
If you believe health information is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by the office. To request an amendment, complete and submit a CLINICAL RECORD AMENDMENT/CORRECTION FORM to the Privacy Officer listed at the top of this form.
We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- ♣ ▪We did not create, unless the person or entity that created the information is no longer available to make the amendment
- ♣ ▪Isnotpartofthehealthinformationthatwekeep
- ♣ ▪Youwouldnotbepermittedtoinspectandcopy
- ♣ ▪Isaccurateandcomplete
Right to an Accounting of Disclosures:
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of clinical information about you for purposes other then treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures we have made based on your written Authorization.
To obtain this list, you must submit your request in writing to the Privacy Officer noted on the top of this Notice. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12- month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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 for it, like a family member or friend. We are not generally required to agree to your request unless the information to be restricted is subject to the written Authorization, is related to the treatment of substance abuse, HIV or genetics. To request restrictions, you may complete and submit the form for REQUESTS FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION to the Privacy Officer listed at the top of this Notice.
Right to Request Confidential Communications:
You have the right to request that we communicate with you about clinical matters in a certain way or at a certain location. For example, you can ask that we contact you at work or by mail. To request confidential communications, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to the Privacy Officer noted at the top of this Notice. We will not ask you the reason for yourrequest. Wewillaccommodateallreasonablerequests. Yourrequestmustspecifyhoworwhereyouwishtobe contacted.
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. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy contact the Privacy Officer noted at the top of this Notice.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice and to make the revised or changed Notice effective for clinical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right-hand corner. You are entitled to a copy of the Notice currently in effect.
If you believe your privacy rights have been violated, you may file a complaint without office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer as noted at the top of this Notice, (715) 748-0251. You will not be penalized for filing a complaint.