Family Counseling Center of Missouri
NOTICE OF PRIVACY PRACTICES
This notice describes how medical and mental health-related information about you may be used and disclosed and, if applicable, how drug- and alcohol-related information about you may be used and disclosed. It also describes how you can get access to this information.
Please review it carefully.
Introduction
At Family Counseling Center, we are dedicated to using and disclosing your protected health information in a responsible way. This notice applies to the medical, mental health, and, if applicable, drug- and alcohol-related records that are generated by Family Counseling Center. The term “protected health information” refers to information you share with us or which arises while we are serving you. Examples may include results of assessments and summaries of your progress in treatment.
This Notice of Privacy Practices explains how we may use and disclose your protected health information and our legal duties to protect the privacy of health records that we create or receive. It also explains your rights as they relate to your protected health information.
This notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.
Confidentiality and Privacy of Client Records
The confidentiality and privacy of client records maintained by this program is in accordance with the ethical standards set by the American Psychological Association, Licensed Professional Counselor Board, Licensed Clinical Social Worker Board, the American Association of Marriage and Family Therapists Board, and laws governing the licensure of these bodies, where applicable. In addition, Family Counseling Center complies with federal regulations. These regulations include the Health Information Portability and Accountability Act (HIPAA) and Federal Confidentiality Regulations (42 CFR Part 2) governing federally assisted alcohol and substance abuse programs.
Information revealed by an individual or individuals, or otherwise obtained by a Family Counseling Center workforce member, will be kept confidential and private. Generally, the program may not say to a person outside the program that a client attends the program or disclose any information identifying a client as someone who has a substance problem. Please note the exceptions listed under “The Type of Use and Disclosures We May Make.”
The Type of Uses and Disclosures We May Make
Generally, your protected health information will be disclosed only if you sign a written authorization. Under certain circumstances, however, we may use and disclose your protected health information without your knowledge and as a part of our regular operations. The following gives you examples of the ways in which your protected health information may be used and disclosed. Not every possible use or disclosure is covered, but all of the ways we are allowed to use and disclose information fall into one of these categories:
• We will use your health information for your treatment at Family Counseling Center.
For example: Information obtained by a Family Counseling Center staff involved in your health care
will be recorded in your clinical record and used to determine the course of treatment that
should work best for you. Information gathered may be used for creating an assessment,
developing a treatment plan, recording your progress in treatment, and assisting in writing
your after-care plan.
• We will use your health information for regular health care operations at Family Counseling Center.
For example: We may use your health information for such quality improvement purposes as reviewing
our treatment and evaluating the performance of our staff in caring for you. To help us
assess the quality of our services, we may ask you to fill out client satisfaction surveys.
• We may disclose your health information to medical personnel in an emergency situation.
For example: If you cannot make decisions because of a medical emergency, we may disclose your
health information to medical personnel involved in your care. We will let you know that
this information has been disclosed and will make every effort to obtain your written
authorization as soon as the emergency situation has ended.
• We will disclose your health information to help prevent serious harm to you or others.
For example: If you tell us, or give us reason to believe, that you have a clear plan to hurt a specific
person or yourself, we will disclose your health information to help prevent serious harm.
However, any such disclosure will be only to someone able to help prevent the threat of
serious harm.
• We will disclose your health information to report incidents of suspected child abuse and/or
neglect.
For example: If you tell us information concerning suspected child abuse and/or neglect, we are required
by Missouri law to disclose this information.
• We may disclose your health information to our business associates.
Some services are provided to Family Counseling Center through our business associates.
For example: Laboratory testing. When services are contracted, we may disclose your health
information to our business associates so they can do the job we’ve asked them to do. Our
contracts with our business associates require them to protect your health information.
• We may disclose your health information to the Food and Drug Administration (FDA).
For example: We may disclose your identity to the FDA if you are taking a medication that FDA
officials have determined may be dangerous to you, due to error in manufacturing or
packaging. The disclosure will allow FDA to notify you or your physician of the problem
so that corrective action may be taken.
• We may disclose your health information to a health oversight agency.
For example: We may disclose your health information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations,
inspections, and licensure. These activities are necessary for the government to monitor
the health care system, government programs, and compliance with civil rights laws. If
you are a private, full-fee client at Family Counseling Center, your health information will
not be disclosed for these purposes.
• We may disclose your health information to respond to third-party payer audits.
For example: Third-party payers may request that we give evidence of services provided. For that
purpose, we allow them to inspect treatment and other records. Your health information
may be requested and reviewed by auditors as part of that process. The information that
auditors review is expected to remain confidential.
• We will disclose your health information to law enforcement, under certain circumstances.
For example: If we receive a court order, we will disclose your health information. If you commit, or
threaten to commit, a crime on the premises or against program personnel, we may
disclose your health information to law enforcement officials. If you are an inmate of a
correctional institution or under the custody of a law enforcement official, we may release
your health information, under certain circumstances.
• We may disclose your health information to enable specialized governmental functions.
For example: We may disclose health information about you to authorized federal officials for
intelligence and other national security activities authorized by law.
• We may disclose your health information to individuals involved in disaster relief.
For example: If a disaster occurs, we may disclose health information about you to some agencies
assisting in a disaster relief effort.
• We may disclose your health information, under certain circumstances, for research purposes.
For example: In limited circumstances, we may disclose your health information for research purposes,
when the Privacy Board of Family Counseling Center has approved a waiver of
authorization. For instance, a research project might involve comparing the health and
recovery of all clients receiving one medication to those receiving another medication for
the same condition.
All research projects have received prior approval of the Privacy Board, which must balance
research needs with clients’ need for privacy of health information. The Privacy Board may
also allow people preparing to conduct research to look at your health information. For
example, a prospective researcher might be looking for clients with specific medical needs.
The health information a prospective researcher reviews may not leave the facility.
• For clients receiving only mental health treatment, we may disclose your health information for
purposes of treatment, payment, and health-care operations.
For example: We may disclose your health information to your physician in order to assist your
treatment. If your insurance coverage is denied, we may disclose your health information
to an alternative funding source in order to receive payment. We may disclose your health
information to coordinate your case management.
• For clients receiving alcohol and drug treatment funded by the Department of Mental Health: Family Counseling Center
of Missouri, Inc. has a Business Associate/Qualified Service Organization Agreement with the Department which allows Family
Counseling Center to disclose PHI to the Department without your written authorization.
For example: We may disclose your PHI for the purposes of treatment such as requesting an extension of
services beyond what is customary. We may disclose your PHI for the purpose of billing
DMH for the services provided to you as well as allowing DMH to audit clinical records
for program evaluation.
(Note: The DMH considers Family Counseling Center of Missouri, Inc. and other
contracted agencies to be members of an Organized Healthcare Arrangement. DMH
considers it permissible to use and/or disclose the DMH Organized Healthcare
Arrangement for purposes of treatment, payment, and healthcare operations.)
• We may disclose your health information when required to do so by law.
For example: We will disclose health information about you when required to do so by federal, state, or
local law.
Your Health Information Rights
Although your health record is the physical property of Family Counseling Center, the information belongs to you. You have the right to:
• Obtain a paper copy of this notice of information practices upon request;
• Inspect and copy your health record as provided for in 45 CFR 164.524;
• Amend your health record as provided in 45 CFR 164.528;
• Request copies of authorizations that we have asked you to sign;
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528;
• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR
164.522;
• Revoke (in writing) your authorization to use or disclose health care information, except to the extent
that action has already been taken.
• Request confidential communication of your health care information. You have a right to request that
We communicate with you about health matters in a certain way or at a certain location. For example,
when we contact you about appointments, treatment information, etc., you can ask that we contact you only
at work or only by mail at your home. To request confidential communications, you must make your request in writing.
Your request must specify how or where you wish to be contacted. We will not ask you the reason for
your request and will accommodate all reasonable requests. In the event that you do not specify how or
where you wish to be contacted, Family Counseling Center will make reasonable efforts not to reveal
our identity and our relationship to you.
Our Responsibilities
Family Counseling Center is required to:
• Maintain the privacy of your health care information;
• Provide you with this notice regarding our legal duties and privacy practices regarding information we collect and
maintain about you;
• Notify you if we are unable to agree to a requested restriction;
• Accommodate reasonable requests you may have to communicate health information in a confidential manner;
• Abide by the terms of this notice.
We reserve the right to change our practices and to make the new provisions effective for all protected health care
information we maintain. If we change our information practices, we will provide a revised notice to you, either in
person or by mail at the address you’ve supplied us. In addition, any revisions to this notice will be posted on the
Family Counseling Center of Missouri, Inc. Web site.
We will not use or disclose your health information without your authorization, except as described in this notice.
We will also discontinue to use or disclose your health care information after we have received a written revocation
of the authorization, according to the procedures included in the authorization.
For More Information or To Report a Problem
If you have questions or would like additional information, you may contact Family Counseling Center’s privacy
officer at 573-443-2204 or write:
Privacy Officer
Family Counseling Center of Missouri, Inc.
117 N. Garth Ave.
Columbia, MO 65203
If you believe your privacy rights have been violated, you may file a complaint with your program’s director or with
the privacy officer at the above address.
If you are receiving services available through the Missouri Department of Mental Health, you may contact and file a
complaint with the department’s Client Rights Monitor at 1-800-364-4687 or by writing:
Missouri Department of Mental Health
Client Rights Monitor
P. O. Box 687
Jefferson City, MO 65102
All persons also have the right to file a complaint with the Office for Civil Rights, U. S. Department of Health and Human Services.
Office for Civil Rights
U. S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D. C. 20201
There will be no retaliation for filing a complaint with Family Counseling Center, the Department of Mental Health, or the Office for Civil Rights.
Acknowledgement Cover Sheet
(To be kept on file in client chart)
I,________________________________________ , hereby acknowledge that I have received the Notice of Privacy Practices
from Family Counseling Center of Missouri, Inc., with an effective date of April 14, 2003.
____________________________________________ _____________________________
Signature of Client, or Date
Signature of Legal Guardian, or
Signature of Parent of Minor Child
