Our Pledge Regarding our health information

At the Mental Health & Recovery Board of Portage County, we understand that
health information about you and your health is personal.  We are committed to protecting
health information about you and safeguarding that information against unauthorized
use or disclosure.  We are required by law to: 1) assure health information that
identifies you is kept private; 2) give you Notice of our legal duties and privacy practices
with respect to health information about you; and, 3) follow the terms of the Notice that is
currently in effect.  This Notice will tell you about the ways in which we may use and
disclose health information about you.  We also describe your rights and certain
obligations we have regarding the use and disclosure of your health information. 
The Notice applies to all of the records that we have related to your care.
 

WHY WE COLLECT PERSONAL HEALTH INFORMATION?

We collect personal information to:

• Determine eligibility for health care coverage
• Provide benefits and pay claims
• Conduct our service evaluation programs
• Provide other information for planning and improving mental health and substance
  abuse services in the community

We may also be required to collect and keep certain information so that we meet
legal and regulatory requirements. We keep this information after a client's health care
coverage ends.

PERSONAL INFORMATION WE COLLECT

We ask people seeking benefits to provide certain information when they complete an
enrollment form. This information may include, for example:

• Name, Address, Phone
• Date Of Birth
• Marital Status
• Social Security Number
• Family Income

We may also receive personal information about you from others, such as:

• Health care providers (doctors, clinics, hospitals)
• Other Alcohol, Drug Addiction and Mental Health Services Boards that provide
  coverage to our clients
• Business partners (companies with whom we have arrangements to assist us
  in providing products and services)
• Other government agencies (criminal justice system, child welfare, juvenile justice, etc.)

The information we collect from others may include, for example, eligibility, claims and
payment information.  We create and maintain a record of your enrollment in the public
mental health and or drug addiction and substance abuse system of the State of Ohio,
and maintain records of payment for treatment you receive in the public system.  From
time to time, we also receive information from your treatment provider related to your
diagnosis, treatment and progress in recovery, and any major unexpected emergencies or
crises you may experience that help the Board to plan for and improve the quality of services
for the region’s citizens. 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

When you receive services paid for in part or in full by the Mental Health & Recovery
Board of Portage County, we may use your personal information for such activities as
conducting our normal board business known as health care operations.  If the services
we paid for were mental health services, we may also use your personal information for
billing for such services. If you have a guardian or a power of attorney we will provide the
information to your guardian or attorney in fact.

Examples of how we use your information include:

Payment for Mental Health Services – We keep records that include payment information
and documentation of the services provided to you. Your information may be used to obtain
payment for your services from Medicaid, insurance or other sources.  For example, we may
disclose personal information about the services provided to you to confirm your eligibility
for Medicaid and to obtain payment from Medicaid. 

Health Care Operations – We use personal information to train staff, manage costs,
conduct required business duties, and make plans to better serve you and other community
residents who may need mental health or substance abuse services.

Other Services We Provide – We may also use your personal information to:

• Review and evaluate the quality, effectiveness, and efficiency of the services
  you have received;

• Conduct program and fiscal audits of programs who have provided you with services;

• Investigate major unusual incidents, report these kinds of incidents and take
  steps to protect your health and safety;

• Prepare reports required by the Ohio Department of Mental Health,
  the Ohio Department of Alcohol and Drug Addiction Services and the Ohio Department
  of Job and Family Services;

• Contact you for assistance in passing levies, unless you notify the
  Mental Health and Recovery Board of Portage County that you do not wish to be
  contacted for these purposes.

Sharing Your Personal Information 

• There are limited situations when we are permitted or required to disclose
  personal information without your signed authorization. These situations are:

• To protect victims of abuse, neglect, or domestic violence;

• To reduce or prevent a serious threat to public health and safety;

• For health oversight activities such as investigations, audits, and inspections; 

• For local, state, federal agencies to monitor your services;

• For lawsuits and similar proceedings;

• For public health purposes such as reporting communicable diseases,
  work-related illnesses, or other diseases and injuries permitted by law; reporting births
  and deaths, and reporting reactions to drugs and problems with medical devices;

• When required by law;

• When requested by law enforcement as required by law or court order,
  except as limited by laws regarding disclosure of alcohol and other drug treatment;

• To coroners, medical examiners, and funeral directors;

• For organ and tissue donation;

• For workers’ compensation or other similar programs if you are injured at
  work and are covered by workers’ compensation or other similar programs;

• 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.
   

SAFEGUARDING YOUR PERSONAL INFORMATION

We maintain physical, electronic and procedural safeguards that comply with applicable
federal and state laws and regulations to guard your personal information against unauthorized
use or disclosure.  Any third party processor or consultant used by the Board has signed an
agreement with us requiring such entity to maintain the confidentiality of your personal
information.  We also restrict access to your personal information to those employees who
need to know the information in order to perform their job duties.  The Board maintains policies
and procedures that prohibit employees and agents of the Board from using, disclosing,
transferring, providing access to or otherwise divulging client health information to any
person or entity other than to the individual who is the subject of the information.

INDIVIDUAL CLIENT RIGHTS

You have the following rights regarding the health information we maintain about you:

• 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 payment or health care
  operations.  We will consider all requests for restrictions carefully but are not required
  to agree to any requested restrictions.*

You also have the right to request a limit on the health information we
disclose about you to a family member who is involved in your care if you are receiving
mental health services and have previously agreed to limited disclosure to such a
family member. We will comply with any restrictions you request regarding disclosure
to such a family member.*  

• Right to Request Confidential Communications   You have the right to request that we
  communicate with you about health matters in a certain way or at a certain location. 
  For example, you can ask that we only contact you at work or by mail. 
   
• Right to Inspect and Copy  You have the right to access the
  personal information we collect upon request. Under certain circumstances, we may not
  share information that we collected, for example, if the information is the subject of a
  lawsuit or legal claim or if release of mental health information may present a danger
  to you or someone else. Fees may apply to copied information.*
   
• Right to Amend  You have the right to request corrections or additions to
  your personal information.  You must give the reasons for wanting the change.*
   
• Right to An Accounting of Disclosures  You have the right to request an
  accounting of disclosures made of your personal information that were not related to
  our business operations or your authorization.  Under certain circumstances, we may
  not share information that we collected, for example, if the information is the subject
  of a lawsuit or legal claim or if release of the information may present a danger to you or
  someone else. Your request must state the period of time desired for the accounting,
  which must be within the six years prior to your request. The first accounting is free
  but a fee will apply if more than one request is made in a 12-month period.*
   
• Right to a Paper Copy of Notice  You have the right to a paper copy of this Notice. 
  Although this Notice is available at our web site www.mental-health-recovery.org,
  you may obtain a copy of the Notice by contacting the Board Office.

Requests marked with a star (*) must be made in writing. Contact the Mental Health &
Recovery Board Privacy Officer with your request. To exercise any of your rights described
in this paragraph, please contact the Board Privacy Officer at the address or phone number
listed below.

Hal Farrier
P.O. Box 7
Kent, OH 44240
330-673-1756

Email: half@mental-health-recovery.org
 

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time.  We reserve the right to make
the revised or changed Notice effective for health information we already have about
you as well as any information we receive in the future.  We will post a copy of the current
Notice at the Board Office.  The Notice will contain on the first page in the top center, the
effective date.  In addition, each time there is a change in the Notice, you will receive
a copy by mail at the last known address we have in our plan enrollment file.

COMPLAINTS

If you have a complaint about our Privacy policies and procedures or you believe
your privacy rights have been violated, you may file a complaint with the Board or with the
Secretary of the Department of Health and Human Services.  To file a complaint with the Board,
contact the Privacy Officer at the address below.  We will investigate all complaints and will not
retaliate against you for filing a complaint.  If you wish to file a complaint with the Secretary you
may send the complaint to:

HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244
 

OTHER USES OF PERSONAL HEALTH INFORMATION

Other uses and disclosures of your personal health information not covered by this Notice or
the laws that apply to us will be made only with your written permission.  If you provide us
permission to use or disclose health 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
health information for the reasons covered by your written permission.  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 services that we provided to you.

Hal Farrier
P.O. Box 743
Kent, OH 44240
330-673-1756

Email: half@mental-health-recovery.org

Effective: April 14, 2003

The Mental Health & Recovery Board of Portage County
PO Box 743, Kent Ohio 44240
An equal opportunity service provider and employer
© 2003 The Mental Health & Recovery Board of Portage County
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