Privacy Practices

SAFE HARBOR NOTICE OF PRIVACY PRACTICES — SAFE HARBOR PROGRAMS, INC.
SAFE HARBOR TREATMENT CENTER
NOTICE OF PRIVACY PRACTICES

Safe Harbor Programs, Inc. (Referred to as “Safe Harbor” throughout this document) is committed to protecting the confidentiality of your medical information, and is required by law to do so. This Notice describes how we may use your medical information within Safe Harbor and how we may disclose it to others outside the program. This Notice also describes the rights you have concerning your own health information. Please review it carefully and let us know if you have any questions.

HOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?
Treatment: We may use your medical information to provide you with medical services and supplies. With your written consent, we may disclose your medical information to doctors, physician assistants, nurses, medical providers, nursing students, technicians, therapists, psychologists, psychiatrists, emergency service and medical transportation providers, medical equipment providers, and others involved in your care. For example, we may allow your primary therapist at Safe Harbor to have access to your medical record to assist in your treatment.

We may disclose medical information to you to offer you health related services that are relevant to your care.
Family Members And Others Involved In Your Care: We may disclose your medical information with your signed authorization to a family member or friend who is involved in your treatment, or to someone who helps to pay for your care. You maintain the right to rescind your authorization at any time by contacting our Clinical Director. During the course of a treatment session in person or by telephone when you and family members or friends are present, Safe Harbor may disclose your medical information with your verbal agreement. We may also disclose your medical information to disaster relief organizations to help locate a family member or friend in a disaster. If you do not want Safe Harbor to disclose medical information to family members or others, please contact the program.

Payment:
We may use and disclose your medical information to third party payers such as insurance companies who sometimes request medical records before paying for services.

Quality of Care:
We may use or disclose your medical information to improve the quality of care we provide to patients or for the operation of Safe Harbor. We may use your medical information to conduct quality improvement assessments; for accounting or legal services; to obtain medical record transcription services; or to conduct business management and planning. For example, we may look at your medical record to evaluate whether Safe Harbor’s staff did a good job.

Clinical Research:
We may discretely use or disclose your medical information for certain research projects at facilities/designated and authorized to do so. All research studies protect the confidentiality of your medical information.

Required by Law:
Federal, state and local laws sometimes require us to disclose patients’ medical information. We are required to report child abuse/neglect and must provide certain information to law enforcement officials in domestic violence cases. State Workers Compensation Program also mandates us to give them information for work-related injuries.

Public Health:
If indicated we retain the right to report certain medical information for public health purposes. For instance, we are required to report births, deaths, and communicable diseases to the State. For public protection we may report patient problems with medications or medical products to the FDA.

Public Safety:
We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We may disclose medical to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, to report criminal conduct at Safe Harbor, to prevent a serious threat to your or another person’s health or safety.

Government Oversight:
We may disclose medical information to government agencies that oversee Safe Harbor or its personnel, such as the California Department of Health and the Board of Behavioral Science. These agencies need medical and clinical information to monitor compliance with state and federal laws and ethical codes.

Military, Veterans, National Security, and Other Government Purposes: If you are a member of the armed forces, we may release your medical information as required by military command authorities or to the Department of Veterans Affairs. Safe Harbor may disclose medical information to federal officials for intelligence and national security purposes or for Presidential Protective Services.

Judicial Proceedings:
Safe Harbor may disclose medical information in a lawsuit if Safe Harbor is ordered to do so by a court or if Safe Harbor receives a subpoena. Patients usually will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your medical information. Providers are entitled disclose information to their own legal counsel, or anyone working on behalf of their legal counsel, in providing representation to the provider.

Other Uses and Disclosures:
If Safe Harbor wishes to use or disclose your medical information for a purpose that is not discussed in this Notice, Safe Harbor will seek your permission. If you give your permission to Safe Harbor, you may take back that permission at any time, unless we have already relied on your permission to use or disclose the information. If you would ever like to revoke your permission, please notify Safe Harbor’s Clinical Director in writing.

WHAT ARE YOUR RIGHTS?
Right to Request Your Medical Information: You have the right to look at your own medical information and to get a copy of that information. Safe Harbor has a policy governing this procedure and time frame. The law requires us to keep the original record, but you may receive a copy of your medical record, your billing record, and other records we use to make decision about your care. In order to receive your medical record information, submit a written request to the Clinical Director. If you request a copy of your information, we will charge you for our costs to copy the information. We will tell you in advance what this copying cost will be. You can look at your record at no cost to you.

Right to Request Amendment of Medical Information:
If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record. To make a request to amend your medical information, submit a written request to the Clinical Director.

Right to Get a List of Certain Disclosures of Your Medical Information:
You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, submit a written request to the Clinical Director. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance what these additional requested lists will cost.

Right to Request Restrictions on How Safe Harbor Will Use or Disclose Your Medical Information:
For Treatment, Payment, or Health Care Operations: You have the right to request us not to make uses or disclosure of your medical information to treat you, to seek payment for care, or to operate Safe Harbor. We are not required to agree to your request, but if we do agree, we will comply with that agreement. If you want to request a restriction, submit your request in writing to the Clinical Director and describe your request in detail.

Right to Request Confidential Communications:
You have the right to request that we communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, submit your request in writing to the Clinical Director. You can also ask to speak with your therapist and/or group facilitator in private outside the presence of other patients–just ask them!

Right to a Paper Copy:
If you have received this Notice electronically, you have the right to a paper copy at any time. You may download a paper copy of this Notice from our website, at www.safeharborprograms.com, or you may obtain a paper copy of the notice from the Admissions Department.

CHANGES TO THIS NOTICE.
From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new Notice effective for all medical information we maintain. If we change these at any time you can download at copy from our website, www.safeharborprograms.com. All patients being treated when a revised Notice is published will receive a copy of the revised Notice from the Clinical Director.

WHICH HEALTH CARE PROVIDERS ARE COVERED BY THIS NOTICE?
This Notice of Privacy Practices applies to Safe Harbor and its personnel, volunteers, students, and interns. This Notice also applies to health care providers who are not employed by Safe Harbor but who care for patients at Safe Harbor, such as physicians, therapists, psychologists and dieticians, unless those care providers give you their own Notice. Safe Harbor may share your medical information with these providers for treatment purposes, to get paid for treatment, or to conduct health care operations. These health care providers may follow different privacy practices at their own offices or facilities.

DO YOU HAVE CONCERNS OR COMPLAINTS?
Please tell us about any problems or concerns you have with your privacy rights or how Safe Harbor uses or discloses your medical information. If you have a concern, please contact Safe Harbor’s Clinical Director. If for some reason Safe Harbor cannot resolve your concern, you may also file a complaint wit the Department of Health and Human Services by sending DHHS your complaint in writing (either on paper or electronically), to Regional Manager, CMS Region IX, 50 United Nations Plaza, Rm. 32, San Francisco, CA 94102. We will not penalize you or retaliate against you in any way for filing a complaint with the federal government.

DO YOU HAVE QUESTIONS?
Safe Harbor is required by law to give you this Notice and to follow the terms of the Notice currently in effect. If you have any questions about this Notice, or have further questions about how Safe Harbor may use and disclose your medical information, please contact Safe Harbor’s Clinical Director, Darlene Manick, at (818) 702-1312, 21201 Victory Boulevard, Suite 200, Woodland Hills, California 91303.

Effective Date: November ____, 2009. Current revision date: ____________

By signing below, I certify that I have received a copy of this Notice of Privacy Practices, and have read and understand it in its entirety.

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