JOINT NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL (INCLUDING MENTAL HEALTH INFORMATION) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
During the process of providing services to you, Centennial Mental Health Center, Inc. will obtain, record and use mental health and medical information about you that is protected health information. Ordinarily that information is confidential and will not be used or disclosed, except as described below.
I. USES AND DISCLOSURES OF PROTECTED INFORMATION
A. General Uses and Disclosures Not Requiring the Client Consent. Centennial Mental Health Center, Inc. will use and disclose protected health information in the following ways:
1. Treatment. Treatment refers to the provision, coordination, or management of health care (including mental health care) and related services by one or more health care providers. For example, Centennial Mental Health Center, Inc. staff involved with your care may use your information to plan your course of treatment and consult with other staff to ensure the most appropriate methods are being used to assist you.
2. Payment. Payment refers to the activities undertaken by a health care provider (including mental health care) to obtain or provide reimbursement for the provision of health care. For example, Centennial Mental Health Center, Inc. will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company for services provided. The information provided to insurers and other party payers may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment. If you are covered by Health First Colorado (Colorado’s Medicaid Program), information will be provided to Health First Colorado (Colorado’s Medicaid Program), including but not limited to your treatment, condition, diagnosis, and service received.
3. Health Care Operations. Health Care Operations refers to activities undertaken by Centennial Mental Health Center, Inc. that are regular functions of management and administrative activities. For example, Centennial Mental Health Center, Inc. may use your health information in monitoring the service quality, staff training and evaluation, medical review, legal services, auditing functions, compliance programs, business planning, and accreditation, certification, licensing, and credentialing activities.
4. Contacting the Client. Centennial Mental Health Center, Inc. may contact you to remind you of appointments, to tell you about or recommend possible treatment options or alternatives that may be of interest to you, and to tell you about health-related benefits or other services that might be of benefit to you.
5. Required by Law. Centennial Mental Health Center, Inc. will disclose protected health information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect; (b) when court ordered to release information, provided that you have been given specific notice and an opportunity for a hearing; (c) where there is legal duty to warn or take action regarding imminent danger to a specific person or persons; (d) when required to report certain communicable diseases and certain injuries; and (e) when a Coroner is investigating the client’s death.
6. Health Oversight Activities. Centennial Mental Health Center, Inc. may disclose protected health information to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefits programs, regulatory programs, or determining compliance with program standard.
7. Crimes on the premises or observed by Centennial Mental Health Center, Inc. personnel. Crimes that are observed by Centennial Mental Health Center, Inc. staff that are directed toward staff or occur on the Center’s premises will be reported to law enforcement.
8. Business Associates. Some of the functions of Centennial Mental Health Center, Inc. are provided by contracts with business associates. For example, some administrative, clinical, quality assurance, billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform their services. In those situations, protected health information will be provided to those contractors as needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
9. Research. Centennial Mental Health Center, Inc. may use or disclose protected health information for research purposes if the relevant limitation of the Federal HIPAA Privacy Regulation and applicable state laws are followed.
10. Involuntary Clients. Information regarding clients who are being treated involuntarily, pursuant to the law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed.
11. Family Members. Except for certain minors, incompetent clients, or involuntary clients, and in other limited circumstances, protected health information cannot be provided to family members without the client’s consent. In situation where the family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
12. Fund Raising. Centennial Mental Health Center, Inc., or its fund raising Foundation, may contact clients as part of its fund raising activities. In such cases, Centennial Mental Health Center, Inc. will disclose only limited information about clients including: demographic information (name, address, other contact information, age, gender, and date of birth); date of health care provided; department of services; treating physician; whether there was a positive or negative outcome; and health insurance status. If a client does not want us to contact them for fundraising efforts, the client has the right to opt-out of receiving such communications.
13. Confidentiality of Alcohol and Drug Abuse Patient Records. The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:
1) The patient consents in writing;
2) The disclosure is allowed by a court order; or
3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
(See 42 U.S.C. 290ee for Federal laws and 42 C.F.R. Part 2 for Federal regulations.) [42 C.F.R. §2.22]
B. Client Authorizations or Release of Information. Other uses and disclosures of protected health information not covered by this Notice or the laws that apply to us will be made only with your written permission, including (i) most uses and disclosures of psychotherapy notes; (ii) most uses and disclosures of your protected health information for marketing purposes; and (iii) disclosures that constitute the sale of your protected health information. If you provide us permission to use or disclose 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 your protected health information for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
II. YOUR RIGHTS AS A CLIENT
A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the protected health information the Center has regarding you, in the designated record set. There are some limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, contact your local Centennial Mental Health Center, Inc. office.
B. Amendment to Your Record. You have the right to request that the Center amend your protected health information. Centennial Mental Health Center, Inc. is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant along with the appeal process available to you. To make a request, contact your local Centennial Mental Health Center, Inc. office.
C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures Centennial Mental Health Center, Inc. has made regarding your protected health information in the six (6) years immediately preceding your request. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you or disclosures made pursuant to a signed Authorization. There are other exceptions that will be provided to you, should you request an accounting. To make a request, contact your local Centennial Mental Health Center, Inc. office.
D. Additional Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for your treatment, payment, or health care operations. You also have the right to request a limit on the protected 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 unless your request is that we not disclose information to a health plan for payment or health care operations activities when you have paid for services that are the subject of the information out-of-pocket in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To make a request, contact your local Centennial Mental Health Center, Inc. office.
E. Alternative Means of Receiving Confidential Communication. You have the right to request that you receive communication of protected health information from Centennial Mental Health Center, Inc. by alternative means or at alternative locations. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, contact your local Centennial Mental Health Center, Inc. office.
F. Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request at any time, even if you have agreed to receive this Notice electronically.
III. ADDITIONAL INFORMATION
A. Privacy Laws. Centennial Mental Health Center, Inc. is required by State and Federal law to maintain the privacy of protected health information. In addition, Centennial Mental Health Center, Inc. is required to provide clients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of this notice.
B. Terms of this Notice and Changes to the Notice. Centennial Mental Health Center, Inc. is required to abide by the terms of this Notice, or any amended Notice that may follow. Centennial Mental Health Center, Inc. reserves the right to change the terms of the Notice to make the new Notice provision effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted in Centennial Mental Health Center’s service delivery sites as well as on the Center’s website, WWW.CentennialMHC.org. A printed Notice is available upon request.
C. Time Frame to File Complaint Relating to Maintenance of Records. Any person who alleges that a non-medical mental professional has violated the licensing laws related to the maintenance of records for a client eighteen (18) years or older, must file a complaint or other notice with the licensing board within seven (7) years after the person discovered or reasonably should have discovered this. Pursuant to law, this practice will retain individual records for adults for seven (7) years from the date of discharge and for individuals who are under eighteen (18) years of age when admitted to the agency, until the individual is twenty-eight (28) years of age.
D. Breach Notification. Centennial Mental Health Center, Inc. is required to notify you following a breach of your protected health information that has not been secured in a certain manner.
E. Complaints Regarding Privacy Rights. If you believe that Centennial Mental Health Center, Inc. has violated your privacy rights, you have the right to complain to Centennial Mental Health Center, Inc. management. To file your complaint, call the Centennial Mental Health Center, Inc. Privacy Officer at (970) 522-4549. You also have the right to complain to the officer for the Office of Civil Rights, U.S. Department of Health and Human Services, 1961 Stout Street – Room 1426, Denver, CO 80294; telephone: (303) 844-2024; (303) 844-3439(TDD); (303) 844-2025 (FAX). For Alcohol and Drug Abuse Patients who believe that Centennial Mental Health Center, Inc. has violated your privacy rights, you also have the right to complain to the United States Attorney’s Office, District of Colorado, 1801 California Street, Suite 1600, Denver, CO 80202, (303) 454-0100, (303) 454-0400 (FAX). It is the policy of Centennial Mental Health Center, Inc. that there will be no retaliation for your filing of such complaints.
F. Additional Information. If you desire additional information about your privacy rights at Centennial Mental Health Center, Inc., please call the Client Experience Coordinator at (970) 522-4549
G. Effective Date. This Notice is effective January 12, 2024.
AUTHORIZATION FOR PROVISION OF UNENCRYPTED ELECTRONIC HEALTH INFORMATION (ePHI) AND USE OF THE UNENCRYPTED EMAIL
I, hereby authorize Centennial Mental Health Center, Inc. medical staff, clinical staff, and allied professional staff (“Centennial Mental Health Center, Inc.”) to provide copies of my Electronic Protected Health Information (“ePHI”), to me or my Personal Representative, in accordance with applicable Centennial Mental Health Center, Inc. policies and procedures, in a format that is not Encrypted.
I understand and acknowledge that these types of communication and ePHI that are transmitted to me and are not encrypted are subject to a risk of interception and/or unauthorized access by third parties, including but not limited to my employer, if I utilize work email for communications described here. I understand and agree that Centennial Mental Health Center, Inc. shall not be liable or responsible for interception of, or unauthorized access to, my ePHI or email that is provided or transmitted to me by Centennial Mental Health Center, Inc. in a form that is not Encrypted. Further, Centennial Mental Health Center, Inc. is not responsible for safeguarding ePHI that has been provided to me and that is not Encrypted (e.g., if a CD-ROM or other devices used to provide unencrypted ePHI to me).
Centennial Mental Health Center, Inc. also has the right to refuse to provide ePHI to me on external portable media by me (e.g., CD-ROM or flash drive) if Centennial Mental Health Center, Inc. determines there is an unacceptable level of risk to its systems and security in utilizing such external portable media. Where Centennial Mental Health Center, Inc. has made such a determination, the Center will use email to communicate and provide ePHI to me.
All capitalized terms used and not otherwise defined in this Authorization shall have meanings set forth in the Health Insurance and Portability Accountability Act of 1996 (“HIPAA”) and/or its accompanying regulations.
PERMISSION TO COMMUNICATE WITH YOU BY TEXT OR OTHER UNENCRYPTED MEANS
By signing this Notice, I authorize Centennial Mental Health Center, Inc. to communicate with me by email, texts, telephone, or through other types of media that are not encrypted and, thus, may be deemed by the U.S. Department of Health and Human Services to be unsecure methods of communication, for use cases similar to appointment reminders and appointment cancellation notifications.
Even though Centennial Mental Health Center, Inc. and your therapist provide behavioral health services, federal law requires that we tell adult clients with Health First Colorado (Colorado’s Medicaid Program) about Colorado laws relating to your right to make health care decisions and Advance Directives. Your provider will provide behavioral health care whether or not you have an Advance Directive.
What is a Medical Advance Directive? Advance Directives are written instructions that express your wishes about the kinds of medical care you want to receive in an emergency. In Colorado, Medical Advance Directives include:
-Medical Durable Power of Attorney: This means a person you trust to make medical decisions for you if you cannot speak for yourself.
-Living Will: This tells your doctor what type of life supporting procedures you want and do not want.
-Cardiopulmonary Resuscitation (CPR) Directive or “Do Not Resuscitate Order”: This tells medical personnel not to revive you if your heart or lungs stop working.
Your provider will ask you if you have an Advance Directive. If you wish, your provider will put a copy of your Advance Directive in your medical file. If a medical provider does not follow your Advance Directive, you may call the Colorado Department of Public Health and Environment at (303) 692-2980. For more information about Advance Directives you can call the Client Experience Coordinator at Centennial Mental Health Center, Inc. at (970) 522-4549.
WELL-CHILD EXAMS (EPSDT)
For Health First Colorado (Colorado’s Medicaid Program) clients under the age of 21, we are required to ask if any behavioral health issues were identified in the last medical visit or well-child exam. We want to address the issues that were identified and coordinate with your Primary Care Physician (PCP). When you provide the name of your child’s Primary Care Physician (PCP), Centennial Mental Health Center, Inc. will contact the PCP to receive the information. If your child has not had a well-child exam within the last year, your therapist will recommend that you schedule an appointment. If you do not have a PCP or you want a new PCP, you may contact Health First Colorado for assistance in Denver at (303) 839-2120; outside of Denver toll-free at 1 (888) 367-6557; TTY at 1 (888) 867-8864.
ORGANIZED HEALTH CARE ARRANGEMENT (“OHCA”)
Centennial Mental Health Center, Inc. (CMHC), North Range Behavioral Health (CMHC), Sunrise Community Health (FQHC), SALUD Family Health Centers (FQHC), Carelon Behavioral Health (ASO), Northeast Health Partners, LLC (ASO), and North Colorado Health Alliance (each a “Party” and collectively the “Parties”) enter into this Organized Health Care Arrangement (“OHCA”). The Parties, as participants in the OHCA, shall have the unrestricted right to use and disclose their patients’ Protected Health Information (“PHI”), as defined by HIPAA, for the treatment, payment, and/or health care operations of the participants, in accordance with federal and state laws.
HOW WE WILL USE AND GIVE OUT YOUR INFORMATION
The OHCA members have agreed to either participate (1) in a clinically integrated care setting where patients may receive health care service from more than one provider; which includes care coordination; or (2) in a joint arrangement that include at least one of the following: (i) utilization review, in which health care decisions by participants are reviewed by other participants or by a third party on their behalf; or (ii) quality assessment and improvement activities, in which treatment provided by the participants are reviewed by other participants or by a third party on their behalf; or (iii) payment activities, if the financial risk for delivering health care is shared, in part or in whole, by participating OHCA members and if PHI created or received by a covered entity is reviewed by other OHCA members or by a third party on their behalf for the purpose of administering the sharing of the financial risk.
SIGNATURE re PRIVACY
This authorization includes, but is not limited to, physical health, mental health, substance use services, and other services or procedures provided face to face via telehealth, which my physician or provider considers necessary. As the client, you retain the option to refuse the delivery of health care services via telemedicine at any time without affecting your right to future care or treatment and without the loss or withdrawal of any program benefits to which you would otherwise be entitled.
I have read and understand this document and my rights as a client or as the client’s responsible party. I agree to participate in treatment at Centennial Mental Health Center, Inc.