Northeastern Mental Health Center
Privacy Statement

Privacy Notice – April 14, 2003

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT OUR PRIVACY OFFICE AT THE ADDRESS OR PHONE NUMBER AT THE BOTTOM OF THIS NOTICE.

Who will follow this notice?
Northeastern Mental Health Center provides behavioral health services to consumers. The informational privacy practices in this notice will be followed by:

NEMHC pledge to you.
NEMHC staff understand that information about you is personal. They are committed to protecting information about you. This notice applies to all of the records of services maintained by NEMHC. By law, NEMHC is required to:

Changes to this Notice.
Policy changes may occur. Such changes will apply to information already held, as well as new information after the change occurs. Before making significant changes in policies, NEMHC will change the notice and post a new notice in waiting areas and on the Web site: http://www.nemhc.org/. You can receive a copy of the current notice at any time. The effective date is listed just below the heading.

How information about you may be used and disclosed.
NEMHC may use and disclose information about you:

• for treatment (such as including another clinician in treatment);
• to obtain payment for treatment (such as sending billing information to your insurance company or Medicare);
• to support health care operation (such as reviewing consumer information to improve quality of care).

Information about you may be used or disclosed without your prior authorization for several other reasons. Subject to certain requirements, information about you may be used or disclosed without prior authorization for abuse or neglect reporting, behavioral care audits or accreditations, and emergencies. Information will also by disclosed when required by law, such as response to a court order. You may also be contacted for appointment reminders, possible treatment options, related benefits or services that may be of interest to you or to support fundraising efforts.

1. Other uses of information
   In any situation not covered by this notice, you will be requested to provide written authorization before information about you is used or disclosed. If you choose to authorize use or disclosure, you can later revoke that authorization by written notification of your decision.
2. Your rights regarding information about you.
1. In most cases, you have the right to look at or get a copy of information used to make decisions about services, when you submit a written request. If your request to review or obtain a copy is denied, you may submit a written request for a review of that decision. If you request copies, a fee may be charged for the cost of copying, mailing or other related supplies.
2. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that records be amended by submitting a written request providing the reason for requesting amendment. Such request to amend a record may be denied if the information was not created by NEMHC; if it is not part of the information maintained by NEMHC; or if it is determined that the record is accurate. You may appeal, in writing, a decision by not to amend a record.
3. You have the right to a list of those instances where information about you has been disclosed, other than for treatment, payment or health care operations, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged based on the cost of producing the list. You will be informed of the cost before incurring any costs.
4. You have the right to a paper copy of this notice.
5. You have the right to request that information be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying NEMHC in writing of the specific way or location to be used to communicate with you.
6. You may request, in writing, that NEMHC restrict the use or disclosure of information about you for treatment, payment or health care operations except when specifically authorized by you, when required by law, or in an emergency. Your request will be considered, but NEMHC is not legally required to accept it. You will be informed of the decision.
7. All written requests or appeals should be submitted to our Privacy Office listed at the bottom of this notice.
3. Complaints

   If you are concerned that your privacy rights may have been violated, or disagree with a decision made about access to your records, you may contact the NEMHC Privacy Office (listed below). You may also contact the NEMHC HIPAA Project Coordinator at (605) 225-1010. Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. The Privacy Officer can provide you the address. Under no circumstance will you be penalized or retaliated against for filing a complaint.

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