This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
How We May Use and Disclose Health Information About You:
For Treatment. We may use medical and clinical information about you to provide you with treatment or services.
For Payment. With your authorization, we may use and disclose medical information about you so that we can receive payment for the treatment services provided to you.
For Health Care Operations. We may use and disclose your protected health information (“PHI”) for certain purposes in connection with the operation of our program and to make sure that all of our clients receive quality care.
We must obtain a written authorization from you for other uses and disclosures of your PHI unless the use or disclosure is required or permitted by law, as explained on the following Pages.
Your Rights Regarding Your PHI
You have the following rights regarding PHI we maintain about you:
- Right of Access to Inspect and Copy.
- You have the right, which may be restricted in certain circumstances, to inspect and copy PHI that may be used to make decisions about your care. We may charge a reasonable, cost based fee for copies.
- Right to Amend.
- If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures.
- You have the right to request an accounting of the disclosures that we make of your PHI.
- Right to Request Restrictions.
- You have the right to request a restriction or limitation on the use of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
- Right to Request Confidential Communication.
- You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
- Right to a Copy of this Notice.
- You have the right to a copy of this notice.
You have the right to file a complaint in writing to us or to the U. S. Secretary of Health and Human Services if you believe we have violated your privacy rights.
We will not retaliate against you for filing a complaint.
Confidentiality of Substance Use Disorder Patient Records
Federal law and regulations protect the confidentiality of substance use disorder patient records. Momentum Recovery is required to comply with these confidentiality protections.
Identifying you as having or having had a substance use disorder may only be provided if allowed under federal regulation. Release of information without your written permission may only be allowed under limited circumstance, such as in response to a court order or to medical personnel in the event of a medical emergency.
Violation of Federal laws or regulations by this program is a crime. Suspected violations of confidentiality should be reported to Momentum Recovery's Privacy Officer. If your concern is not resolved you may also file with your local U.S. Attorney’s Office.
If you commit a crime on program premises or against program personnel, we will disclose information identifying you to law enforcement.
We will make a report of suspected child abuse and neglect, as mandated under state law to appropriate state and local authorities.
The confidentiality of substance use disorder treatment records regulations are found at title 42 of the Code of Federal Regulations (CFR) part 2 (42 CFR part 2).
If you have any questions about this Notice of Privacy Practices, please contact the Momentum Recovery Privacy Officer:
5027 Wrightsville Ave
Wilmington, NC 28403
Your health record contains personal information about you and your health. State and federal law protects the confidentiality of this information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. As referenced in the Client Rights form, this Notice of Privacy Practices describes how we may use and disclose your protected health information (“PHI”) in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”) and regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.
How We May Use and Disclose Health Information About You
Listed below are examples of the uses and disclosures that Momentum Recovery may make of your protected health information (“PHI”). These examples are not meant to be exhaustive. Rather, they describe types of uses and disclosures that may be made.
Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
Treatment. Your PHI may be used by your physician, counselor, program staff and others inside of our program that are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and any related services.
Payment. We will not use your PHI to obtain payment for your health care services without your written consent. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review Activities.
Healthcare Operations. We may use or disclose, as authorized, your PHI in order to support the business activities of our program including, but not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. For example, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician or counselor. We may also call you by name in the waiting room when it is time to be seen. We may contact you to remind you about appointments or to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you. We may also contact you concerning Momentum Recovery's fundraising activities. We may share your PHI with third parties that perform various business activities (e.g., billing or typing services) for Momentum Recovery, provided we have a written contract with the business that prohibits it from redisclosing your PHI and requires it to safeguard the privacy of your protected health information.
Other Uses and Disclosures That Do Not Require Your Authorization
Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the U. S. Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third party payors) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.
Notification and Communication with Family
For organizations only subject to HIPAA:
- We may disclose to a family member, your personal representative or another person responsible for your care, the PHI directly relevant to that person’s involvement in your care or about your location, your general condition or death.
- In the event of an emergency, we may disclose information to public service organizations to facilitate your care.
- We may also disclose information to someone who is involved with your care or helps pay for your care.
- If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in an emergency even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law and to family members, relatives, friends or other individuals indicated by the deceased who were involved either in the deceased’s care or payment for the deceased’s care. We may only disclose PHI that is relevant to the family member, relative, friend or other individual’s involvement in the deceased’s care. If the deceased has expressed a prior preference that PHI not be disclosed to the person in question, we will not disclose PHI to such person. PHI excludes any information regarding a person who has been deceased for more than 50 years.
Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations; and (d) the researchers agree not to redisclose your PHI except back to Momentum Recovery. We may also use or disclose your PHI for research purposes if we obtain your authorization to do so.
Sale of PHI. We are prohibited from disclosing your PHI in exchange for direct or indirect remuneration unless we have obtained your prior authorization to do so.
Marketing. We must obtain your authorization before using or disclosing your PHI for marketing communications that involve financial remuneration. The authorization must disclose the fact that we are receiving financial remuneration from a third party.
Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.
With Authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.
Uses and Disclosures of PHI With Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization at any time, unless the program or its staff has taken an action in reliance on the authorization of the use or disclosure you permitted. However, you may not revoke a criminal justice authorization if you have been mandated to treatment by a court or other applicable criminal justice agency.
Your Rights Regarding your Protected Health Information
Your rights with respect to your PHI are explained below. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.
You have the right to inspect and copy your Protected Health Information
You may inspect and obtain a copy of PHI that is contained in a designated record set for as long as we maintain the record. A “designated record set” contains medical and billing records and any other records that the program uses for making decisions about you. Your request must be in writing. We may charge you a reasonable cost based fee for the copies. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right to appeal the denial of access. You may also request that a copy of your PHI be provided to another person. Please contact our Privacy Officer if you have questions about access to your medical record.
You may have the right to amend your Protected Health Information
You may request, in writing, that we amend PHI that has been included in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of it. Please contact our Privacy Officer if you have questions about amending your medical record.
You have the right to receive an accounting of some types of Protected Health Information disclosures
You may request an accounting of disclosures for a period of up to six years, excluding disclosures made to you, made for treatment purposes or made as a result of your authorization. We may charge you a reasonable fee if you request more than one accounting in any 12 month period. Please contact our Privacy Officer if you have questions about accounting of disclosures.
You have a right to receive a copy of this notice
You have the right to obtain a copy of this notice from us. Any questions should be directed to our Privacy Officer.
You have the right to request certain restrictions on disclosures of PHI
You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions. Please contact our Privacy Officer if you would like to request restrictions on the disclosure of your PHI.
You have a right to request confidential communications
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable, written requests. We may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. We will not ask you why you are making the request. Please contact the Privacy Officer if you would like to make this request.
You have a right to an electronic copy of your electronic medical records
If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost based fee for the labor associated with transmitting the electronic medical record.
You have the right to get notice of a breach of your PHI
You have the right to be notified upon a breach of any of your unsecured PHI.
If you believe we have violated your privacy rights, you may file a complaint in writing to us by notifying our Privacy Officer, at 5027 Wrightsville Ave, Wilmington, NC 28403 888.815.5502
You may also file a complaint with the U. S. Secretary of Health and Human Services as follows:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
We will not retaliate against you for filing a complaint.