THIS NOTICE CONTAINS INFORMATION CONCERNING HOW CONFIDENTIAL MENTAL HEALTH TREATMENT INFORMATION CONCERNING YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND LET US KNOW ANY QUESTIONS THAT YOU MAY HAVE CONCERNING THIS NOTICE.

During the process of providing services to you, Peter Marsh will obtain and use mental health and medical information concerning you that is both confidential and privileged. Ordinarily this confidential information will be used in the manner that is described in this statement, and will not be disclosed without your consent, except for the circumstances described in the Notice.

I. USES AND DISCLOSURES OF PROTECTED INFORMATION

A. General uses and disclosures not requiring the Patient’s Consent. PETER MARSH will use and disclose protected health information in the following ways.

1. Treatment. Treatment refers to the provision, coordination, or management of mental health care and related services by one or more health providers. For example, PETER MARSH and staff involved with your care may use your information to plan your course of treatment and consult with other health care professionals or their staff concerning services needed or provided to you.

2. Payment. Payment refers to the activities undertaken by a health care provider to obtain or provide reimbursement for the provision of health care. For example, PETER MARSH and other health care professionals will use information that identifies you, including information concerning your diagnosis, services provided to you, dates of services, and services needed by you, and may disclose such information to insurance companies, to businesses that review bills for health care services and handle claims for payment of health care benefits in order to obtain payment for services. If you are covered by Medicaid, information may be provided to the State of Colorado’s Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received.

3. Health Care Operations. Health Care Operations means activities undertaken by health insurance companies, businesses that administer health plans and companies that review bills for health care services in order to process claims for health care benefits. These functions include management and administrative activities. For example, such companies may use your health information in monitoring of service quality, staff training and evaluation, medical reviews, legal services, auditing functions, compliance programs, business planning and accreditation, certification, licensing and credentialing activities.

4. Contacting the Patient. PETER MARSH may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.

5. Required by Law. PETER MARSH will disclose protected health information when required by law. This includes, but is not limited to: (a) reporting child abuse or neglect to the Department of Human Services or to law enforcement; (b) when court ordered to release information; (c) when there is a legal duty to warn of a threat that a patient has made of imminent physical violence, health care professionals are required to notify the potential victim of such a threat, and report it to law enforcement; (d) when a patient is imminently dangerous to himself/herself or to others, or is gravely disabled, health care professionals may have a duty to hospitalize the patient in order to obtain a 72-hour evaluation of the patient; and (e) when required to report a threat to the national security of the United States.

6. Health Oversight Activities. Your confidential, protected health information may be disclosed to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, and regulatory programs or determining compliance with program standards.

7. Crimes on the premises or observed by PETER MARSH or personnel. Crimes that are observed by PETER MARSH and staff that are directed toward staff, or occur on the premises will be reported to law enforcement.

8. Business Associates. Confidential health care information concerning you, provided to insurers or to plans for purposes or payment for services that you receive may be disclosed to 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 contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.

9. Research. Protected health information concerning you may be used with your permission for research purposes if the relevant provisions of the Federal HIPAA Privacy Regulations are followed.

10. Involuntary Patients. Information regarding patients who are being treated involuntarily, pursuant to 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 in compliance with Colorado law.

11. Family Members. Except for certain minors, incompetent patients, or involuntary patients, protected health information cannot be provided to family members without the patient’s consent. In situations where family members are present during a discussion with the patient, and it can be reasonably inferred from the circumstances that the patient does not object, information may be disclosed in the course of that discussion. However, if the patient objects, protected health information will not be disclosed.

12. Emergencies. In life threatening emergencies PETER MARSH will disclose information necessary to avoid serious harm or death.

B. Patient Release of Information or Authorization. PETER MARSH and other health care professionals may not use or disclose protected health information in any way without a signed release of information or authorization. When you sign a release of information, or an authorization, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent PETER MARSH has already taken action in reliance thereon.

II. YOUR RIGHTS AS A PATIENT
A. Access to Protected Health Information. You have the right to receive a summary of confidential health information concerning mental health services needed or provided to you. 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, ask PETER MARSH for the appropriate request form.

B. Amendment of Your Record. You have the right to request that PETER MARSH or your health care professionals amend your protected health information. PETER MARSH 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, ask PETER MARSH for the appropriate request form.

C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures PETER MARSH has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operation. In addition, the accounting does not include disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an accounting. To make a request, ask PETER MARSH for the appropriate request form.

D. Additional Restrictions. You have the right to request additional restriction on the use of disclosure of your health information. PETER MARSH does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To make a request, ask PETER MARSH for the appropriate request form.

E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from PETER MARSH by alternative means or at alternative locations. For example, if you do not want PETER MARSH to mail bills or other materials to your home, you can request that this information be sent to another address. 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, ask PETER MARSH for the appropriate request form.

F. Copy of this Notice. You have a right to obtain another copy of this Notice upon request.

III. ADDITIONAL INFORMATION
A. Privacy Laws. PETER MARSH is required by State and Federal law to maintain the privacy of protected health information. In addition, PETER MARSH is required by law to provide patients 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 the Notice and Changes to the Notice. PETER MARSH is required to abide by the terms of this Notice, or any amended Notice that may follow. PETER MARSH reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted in PETER MARSH service delivery sites and will be available upon request.

C. Complaints Regarding Privacy Rights. If you believe PETER MARSH has violated your privacy rights, you have the right to complain to PETER MARSH management. Please submit a statement in writing addressed to PETER MARSH 5080 Mark Dabling Blvd, Colorado Springs, CO 80918 concerning your complaint and the basis for it. You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 515F, HHH Building, Washington D.C., 20201. It is the policy of PETER MARSH that there will be no retaliation for your filing of such complaints.

D. Additional Information. If you desire additional information about your privacy rights with PETER MARSH please ask me any questions that you may have.

IV. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

A. The confidentiality of alcohol and drug abuse patient records maintained by PETER MARSH is protected by Federal law and PETER MARSH’s 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 comments 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.

B. 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.

C. 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. Disclosure may be made concerning any threat made by a patient to commit imminent physical violence against another person to the potential victim who has been threatened and to law enforcement.

D. Federal law 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.

V. EFFECTIVE DATE, THIS NOTICE IS EFFECTIVE FEBRUARY 1, 2012
I understand these disclosures. I have received a copy of this Disclosure Statement and Notice of Privacy rights.


PLEASE PRINT A COPY FOR YOUR RECORDS.