Effective Date: April 30, 2018

Reviewed on: March 01, 2024

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL 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 about this Notice, please contact the Privacy Officer 833-356-8733

This Notice applies to Elm Tree Clinic.

NOTICE OF PRIVACY PRACTICES

Elm Tree Clinic is required by law to provide you with this Notice so that you will understand how we may use or share your health information from your Designated Record Set. The Designated Record Set includes financial and health information referred to in this Notice as “Protected Health Information” (“PHI”) or simply “health information.”

UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION

Protecting patient privacy is an important element of the trust between our caregivers and their patients, and an important legal and ethical obligation. Elm Tree Clinic is committed to protecting our patients' rights to privacy, and to safeguarding patient information.

Information relating to your treatment at Elm Tree Clinic is protected by federal regulations specific to substance use disorders (SUD), which are known as 42 CFR Part 2. These regulations protect the confidentiality of information related to the identity, diagnosis, prognosis, or treatment of any patient in a SUD treatment program. Elm Tree Clinic may not disclose records relating to your health information without your written consent, except in narrowly limited circumstances as permitted by 42 CFR Part 2.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION

Treatment: We may use or disclose your protected health information for treatment purposes. Treatment includes diagnosis, treatment, and other services, including discharge planning.

For example, Elm Tree Clinic counselors and providers may disclose your health information to each other to coordinate care for your treatment or information about treatment alternatives or other health-related benefits and services that are necessary or may be of interest to you.

Health Care Operations: We may use or disclose your protected health information for the purposes of health care operations that include billing and payment activities, internal administration and planning and various activities that improve the quality and effectiveness of care.

For example, we may use information about your care to evaluate the quality and competence of our clinical staff. We may disclose information to qualified personnel for outcome evaluation, management audits, financial audits, or program evaluation; however, such personnel may not identify, directly or indirectly, any individual patient in any report of such audit or evaluation, or otherwise disclose patient identities in any manner.

We may disclose your information as needed within Elm Tree Clinic in order to resolve any complaints or issues arising regarding your care.

We may also disclose your protected health information to an agent or agency which provides services to Elm Tree Clinic under a qualified service organization agreement and/or business associate agreement, in which they agree to abide by applicable federal law and related regulations (42 CFR Part 2 and HIPAA).

This list of examples is for illustration only and is not an exclusive list of all of the potential uses and disclosures that may be made for health care operations.

OTHER ALLOWABLE USES AND DISCLOSURES WITHOUT YOUR AUTHORIZATION INCLUDE:

Appointment Reminders. We may use your health information to contact you with reminders about your appointments and other of our services that may be of interest to you.

Medical Emergencies. We may disclose your health information to the extent necessary to meet a bona fide medical emergency (as defined by 42 CFR Part 2), to medical personnel for the purpose of treating a condition which poses an immediate threat to your health and which requires immediate medical intervention.

For example, if you are admitted to an emergency department, and the admitting/treating provider needs the list of medications you’re being prescribed by our provider to be able to provide immediate medical intervention.

Help with public health and safety issues. We can share health information about you for certain situations such as:

• Preventing disease

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone's health or safety

Do research. We may use or disclose protected health information without your consent or authorization if our research privacy board approves a waiver of authorization for disclosure.

Commission of a Crime on Premises or against Program Personnel. We may disclose your protected health information to the police or other law enforcement officials if you commit a crime on the premises or against program personnel or threaten to commit such a crime.

Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Decedents. We may disclose your health information to a coroner, medical examiner or other authorized person under laws requiring the collection of death or other vital statistics, or which permit inquiry into the cause of death.

Audit and Evaluation Activities. We may disclose protected health information to those who perform audit or evaluation activities for certain health oversight agencies, e.g., state licensure or certification agencies, the Department of Public Health, which oversees the health care system and ensures compliance with regulations and standards, or those providing financial assistance to the program.

Respond to lawsuits and legal actions. We may disclose your protected health information in response to a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records. Note also that if your records are not actually “patient records” within the meaning of 42 CFR Part 2.

For example, if your records are created as a result of your participation in the family program or another non-treatment setting, your records may not be subject to the protections of 42 CFR Part 2.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written consent. If you provide us a consent to use or disclose your health information, 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 about. 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 care that we provided to you.

Under 42 CFR Part 2, the terms of a written consent to disclose information must specify the scope and types of information to be disclosed, the parties to whom the information may be disclosed, the purpose of the disclosure and the timeframe of the consent.

NOTE: We create and maintain psychotherapy notes at Elm Tree Clinic. Psychotherapy notes cannot be disclosed without a valid authorization signed by you except under the very limited circumstances.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Although your health record is the property of the Clinic the information belongs to you. You have the following rights regarding your health information:

• Right to Inspect and Copy. With some exceptions, you have the right to review and get an electronic or paper copy of your health information we have about you. You must submit your request in writing to Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.

• Right to Amend. If you feel that health information in your record is incorrect or incomplete, you may ask us to amend the information. You have this right for as long as the information is kept by or for the Clinic. You must submit your request in writing to Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. In addition, you must provide a reason for your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

• Is not part of the health information kept by or for the Clinic; or

• Is accurate and complete.

RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request an "accounting of disclosures". This is a list of certain disclosures we made of your health information, other than those made for purposes such as treatment, payment, or health care operations.

You must submit your request in writing to Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. Your request must state a time period which may not be longer than six years from the date the request is submitted. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

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 treatment, payment, or our operations.

For example, if you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. You may request that we limit the health information we disclose to someone who is involved in your care or the payment for your care. You could ask that we do not use or disclose information about a certain treatment you had to a family member or friend.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

You must submit your request in writing to Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

RIGHT TO REQUEST ALTERNATE COMMUNICATIONS. You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location.

For example, you may ask that we only contact you via mail to a post office box.

You must submit your request in writing to Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

RIGHT TO A PAPER COPY OF THIS NOTICE. You have the right to a paper copy of this Notice of Privacy Practices even if you have agreed to receive the Notice electronically. You may ask us to give you a copy of this Notice at any time.

You may obtain a copy of this Notice at our website, www.elmtreeclinic.com

To obtain a paper copy of this Notice, contact Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169.

RIGHT TO CHOOSE SOMEONE TO ACT FOR YOU. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. 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 in the Clinic and on the website. The Notice will specify the effective date on the first page, on the top. In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Privacy Officer.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with the Clinic contact Elm Tree Clinic, 21 School Street, Suite 2, Quincy, MA 02169. All complaints must be submitted in writing. You will not be penalized for filing a complaint.