NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective: 4/14/03
Odyssey House, Inc-Utah is committed to protecting your medical information. Odyssey House through its programs is required by law to maintain the privacy of your medical information, provide this notice to you, and abide by the terms of this notice.
HOW WE USE YOUR HEALTH INFORMATION
When you receive services from Odyssey House, protected health information (PHI) about those services is created. Because we are a federally funded substance abuse treatment provider, that information becomes private and is protected by federal law. We may not release it to anyone without your written permission except in limited circumstances. We may use your health information for treating you, billing for services, and conducting our normal business known as health care operations. Examples of how we use your information include:
Treatment—We keep records of the care and services provided to you. Health care and service providers use these records to deliver quality care to meet your needs. For example, an employee of Odyssey House may share your information with other treatment professionals who may assist in your treatment. Some health records, including confidential communications with a mental health professional, may have additional restrictions for use and disclosure under state and federal laws.
Payment—We keep billing records that include payment information and documentation of the services provided to you. Your information may be used to obtain payment from you, your insurance company, or other third party. We may also contact your insurance company to verify coverage for your care or to notify them of upcoming services that may need prior notice or approval. For example, we may disclose information about the services provided to you to claim and obtain payment from your insurance company.
Health Care Operations—We use health information to improve the quality of care, train staff and students, provide customer service, manage costs, conduct required business duties (auditing, business planning, obtaining legal services), and make plans to better serve the community. For example, we may use your health information to evaluate the quality of treatment and services provided by our therapists, social workers (licensing and credentialing, case management, obtaining medical review) and others in our treatment provider network (care coordination).
Other Services We Provide—We may use your health information to recommend treatment alternatives, tell you about health services and products that may benefit you, share information with family or friends involved in your care (with your permission), or payment for your care and share information with third parties who assist us with treatment, payment, and health care operations.
YOUR INDIVIDUAL RIGHTS
You have the right to:
· Request restrictions on how we use and share your health information. We consider all requests for restrictions carefully but are not required to agree to any restriction.
· Request that we use a specific telephone number or address to communicate with you.
· Inspect and copy your health information, including billing records. Fees may apply. Under limited circumstances, we may deny you access to a portion of your health information and you may request a review of the denial.*
· Request corrections or additions to your health information.*
· Request an accounting of certain disclosures of your health information made by us. The accounting does not include disclosures made for treatment, payment, and health care operations and some disclosures required by law. Your request must state the period of time desired for the accounting, which must be within the six years prior to your request and excludes dates prior to April 14, 2003. Except for the costs of photocopying, the first accounting is free. A fee will apply if more that one request is made within a 12-month period.*
· Request a paper copy of this notice even if you agree to receive it electronically.
Requests marked with a star (*) must be made in writing. Contact the Privacy Officer for the appropriate form for your request.
SHARING YOUR HEALTH INFORMATION
There are limited situations when we are permitted or required to disclose health information without your signed authorization. These situations include activities necessary to administer the Medicaid program and the following:
· For public health purposes such as reporting communicable diseases, work-related illnesses, births and deaths.
· To protect victims of abuse, neglect or domestic violence.
· For health oversight activities such as investigations, audits, inspections and administrative actions.
· For lawsuits and similar proceedings.
· When otherwise required by law.
· When requested by law enforcement as required by law or court order.
· To coroners, medical examiners, and funeral directors.
· For organ and tissue donation.
· For research approved by our review process under strict federal guidelines.
· To reduce or prevent a serious threat to public health and safety.
· For workers’ compensation or other similar programs if you are injured at work.
· For specialized government functions such as intelligence and national security.
All other uses and disclosures, not described in this notice, require your signed authorization. You may revoke your authorization at any time with a written statement, except for authorized releases which have already been made. Releases to law enforcement and courts cannot be revoked.
OUR PRIVACY RESPONSIBILITIES
Odyssey House, Inc-Utah is required by law to:
· Maintain the privacy of your health information.
· Provide the notice that describes the ways we may use and share your health information.
· Follow the terms of the notice currently in effect.
We reserve the right to make changes to this notice at any time and make the new privacy practices effective for all information we maintain. Current notices will be posted in the admissions and administrative offices. You may request a copy at any time.
CONTACT US
If you would like further information about your privacy rights, are concerned that your privacy rights have been violated, or disagree with a decision that we made about access to your health information, please contact Odyssey House, Inc. (Utah) Privacy Office at:
344 East 100 South, #301, Salt Lake City, UT 84111
We will investigate all complaints and will not retaliate against you for filing a complaint.
You may also file a written complaint with the Office of Civil Rights at:
200 Independence Avenue, S.W. Room 509F HHH Building, Washington DC 20201
Privacy Notice Page 1
Treatment Agreement
Consent for Treatment ServicesI, ______, hereby request treatment by Odyssey House of Utah, hereinafter referred to as Odyssey House, and recognize and/or consent to the following:
That Odyssey House uses its own form of treatment and accordingly may vary from standard treatment of other treatment facilities. In connection therewith, Odyssey House supplies staff, living facilities, equipment and other provisions relating to the treatment and well-being of residents in accordance with its own abilities.
That Odyssey House is not a secure institution and clients are free to leave at any time. Odyssey House assumes no obligation to provide transportation for any client who elects to leave. Odyssey House will undertake to notify the individual designated as a contact when a client elects to leave, provided that the client has provided contact information and permission. Odyssey House will attempt to contact parents or legal guardians of minor children if a minor leaves the program without permission. That if I, or the minor, am at Odyssey House under court order or other compulsory legal process, and the terms of that order require notification of authorities identified in the order, Odyssey House will notify those individuals. I understand that I am required to notify Odyssey House of any pending criminal matters, including outstanding warrants, and that my failure to do so may result in involuntary discharge.
That Odyssey House has my permission to act in medical and psychiatric matters on my, or the minor’s, behalf, including but not limited to, prescribing and conducting treatment and therapy.
That Odyssey House will make every attempt to ensure proper separation between sexes, but cannot be held responsible for any improper behavior that may occur.
That Odyssey reserves the right to refuse smoking if the client has not smoked within the past three (3) days, if the client comes directly from an institution that does not permit smoking, or if the client is not of legal age to smoke in the State of Utah (age 19). That Odyssey House requires me to abide by the smoking policies, which are posted in each facility and comply with the Utah Clean Air Act.
That Odyssey House has made no promises or guarantees to me whatsoever and that Odyssey House reserves the right to alter its policies or program at any time.
That the basic rules have been discussed with me, including when I, or the minor, may receive visits or phone calls, what possessions I, or the minor, can retain while in treatment, what expectations there are of family and the client, what the consequences are for failure to abide by rules, how the client can be re-admitted if discharged, and when the client can be acceptably absent from the program.
That I, or the minor, is expected to be free of mood altering substance use, including legal substances that have not been approved by the treatment team, and that Odyssey House reserves the right to involuntarily discharge or recommend a higher level of care to clients who are using or appear to be under the influence of an unapproved substance.
That if I have withheld vital information or given false information at any time in the admission process I, or the minor, may be subject to immediate involuntary discharge.
That I freely and voluntarily wish to become a client of Odyssey House and undergo the treatment. That I understand and will abide by all the rules and regulations of Odyssey House.
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Client Signature Legal Guardian Date Case Manager / Witness
Client Rights & Responsibilities
I acknowledge that I have the following rights and responsibilities within Odyssey House:
I have the right to leave treatment at any time. I have the responsibility to weigh my options and make the best decision for me. Re-admittance cannot be guaranteed.
I have the right to communicate frustration or grievances to other clients or staff members. It is my responsibility to initiate this process.
I have the right to be treated with dignity in an environment that supports positive self-image and to not be discriminated against for my cultural and personal values, beliefs or preferences. I have the responsibility to treat others with dignity and respect.
I have the right to communicate with family, attorneys, physicians, clergy, or an advocate and to have access to information regarding my health and treatment except when clinically unadvisable. I have the responsibility to request such communication and adhere to the rules relevant to such communication.
I have the right to receive information regarding my treatment in a manner I can understand. I have the responsibility to request such information.
I have the right to collaboratively make decisions about my treatment (or designate a delegated decision-maker) and involve family in my treatment. I (or my delegate) have the responsibility to be actively engaged in my treatment, including those who I choose to be involved in my treatment.
I have the right to privacy. The information I have given will not be released to anyone who is not part of Odyssey House unless: (a) I am a minor, in which case my legal guardians may have access to specific treatment information; (b) I give consent for this information to be released by signing a release of information form; (c) I have provided information that indicates that either myself or others are at immediate risk, in which case Odyssey House is bound by State law to report the minimum information necessary to protect those individuals; or (d) Odyssey House is forced to release protected information by a court of law. I have the responsibility to maintain other clients’ confidentiality.
I have the right to a clean and safe environment of care. I have the responsibility to fulfill my responsibilities as assigned, including assigned chores, functions, and tasks.
If I am in treatment with my children, I have the right to parent my children and provide for their needs. I acknowledge that I am responsible for the safety, welfare, supervision, and behavior management of my children. I understand that I ultimately must provide any required oversight and arrangements for my children. I acknowledge that my children may be passively restrained (safety hug) if they present an immediate risk of harm to self or others.
I have the right to live in a sober environment free of destructive or dangerous behavior. I have the responsibility to report any suspected use to ensure that staff are aware and to follow the rules of the program myself. Among other reasons, I understand that I may be involuntarily discharged if:
1. I am found in possession of drugs, alcohol, or other items prohibited by the program;
2. I am considered by the program to have stolen property from others;
3. I am considered to have engaged in an act of violence or threatened such conduct;
4. I have engaged in sexual activities prohibited by the program;
5. I am considered to have engaged in child abuse or neglect while in treatment; or I have become aware of the before-mentioned actions by other residents, but have failed to report it to the proper structure.
If I ever feel that these rights have been violated, I have the right to file a complaint. I can do so on my own or request assistance. To report the details about a complaint to The Joint Commission:
Online: http://www.jointcommission.org/generalpublic/complaint
E-mail: Fax: (630)792-5636
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Client Signature Legal Guardian Date Case Manager / Witness
Privacy Notice
I acknowledge that I have received a copy of Odyssey House’s Privacy Policy Notice.
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Client Signature Legal Guardian Date Case Manager / Witness
Fee Collection Policy
I acknowledge receipt of a Financial Agreement identifying fee collection policies and financial arrangements and costs have been discussed with me.