1. Our Duty to Safeguard Your Protected Health Information:

Individually Identifiable Health Information (IIHI) about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered "Protected Health Information" ("PHI"). Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.  We are required to follow the privacy practices described in this Notice, although Westbrook Health Services reserves the right to change our privacy practices and the terms of this Notice at any time. You may request a copy of the notice from any Westbrook Health Services site.  You may also download this Notice in PDF format.

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2. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations: 

• For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team. Your PHI may also be shared with outside entities performing other services relating to your treatment, such as lab work, or for consultation purposes and/or other community agencies involved in provision or coordination of your care.

• To obtain payment: We may use/disclose your PHI to bill and collect payment for your health care services. For example, we may release portions of your PHI to the Medicaid program, Medicare, WV State Bureau for Behavioral Health, and Health Facilities (BHHF), DHHR, a private insurer or other payers to get paid for services that we delivered to you. We may release information to the Office of the Attorney General for collection purposes.  If you pay for your services in full “out-of-pocket”, you may request that we not share your information with your health plan.

• For health care operations: We may use/disclose your PHI in the course of operating our facilities and/or Programs. For example, we may take your photograph for medical identification purposes, use your PHI in evaluating the quality of services provided or disclose your PHI to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in our other facilities, programs, or our central offices for similar purposes.  

• Appointment reminders, Information about Treatment Alternatives, other health-care related benefits and services that may be of interest and fund-raising to benefit Westbrook Health Services: Except for “refill reminders”, unless you provide us with alternative instructions or opt out, we may provide appointment reminders, information about treatment alternatives and other health care-related benefits and services and fund-raising that benefits Westbrook.  If you wish, you may opt out of fund-raising contacts. 

 

3. Uses and Disclosures Requiring Authorization:  

For uses and disclosures beyond treatment, payment, and healthcare operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time except to the extent that we have already undertaken an action in reliance upon your authorization.  Uses and disclosures of any protected health information for marketing purposes and disclosures that constitute the sale of PHI require an authorization.  While Westbrook staff do not maintain “psychotherapy notes”, if such documents exist, they will only be used and disclosed with an authorization.  Other uses and disclosures not described in this Notice will be made only with authorization from you. 

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4.  Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent or Authorization:  

• When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect, advocacy, domestic violence, Duty to Warn or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.

• For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.

• For health oversight activities: We may disclose PHI to our central office, a protection and advocacy agency or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents, and monitoring of federal programs such as the Medicaid program.

• Relating to decedents: We may disclose PHI relating to your death to coroners, medical examiners, or funeral directors, to organ procurement organizations relating to organ, eye, or tissue donations or transplants or for research purposes.  We may disclose PHI to family members and others who were involved in the care or payment for care prior to death, unless doing so would be inconsistent with any prior express preference that you might have had that is known to us.  Otherwise, we must follow the HIPAA Omnibus Privacy Rule with respect to PHI of a decedent.

• For research, audit or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit or evaluation purposes.

• For research purposes: In certain circumstances, and under review of the Human Rights Committee and Westbrook Administration, we may disclose PHI to our central office research staff and their designees to assist medical/psychiatric research.

• To avert threat to health or safety: To avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

• For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President. 

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5. Uses and Disclosures of PHI from Alcohol and Other Drug Records Not Requiring Consent or Authorization:  

The law (42 CFR Part 2 and HIPAA) provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances:

• When required by law: We may disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to a court order that meets the standards set forth by 42 CFR part 2.

• Relating to decedents:  We may disclose PHI relating to your death if state or federal law requires that we provide it for vital statistics collection or for inquiry into cause of death.    

•  To avert threat to health or safety: To avoid a serious threat to health or safety such as your death or as in a Duty to Warn situation, we may disclose PHI.  With respect to the latter, we may disclose PHI to law enforcement when a threat is made to commit a crime against others. 

• Uses and Disclosures Requiring You to have an Opportunity to Object

• In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, if law does not otherwise prohibit the disclosure.

• To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.

 

6. Your Rights Regarding Your Protected Health Information:

• Right to request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request but are not legally bound to agree to the restriction.  Further, you have a right to restrict certain disclosures of Protected Health Information to a health plan where you pay out of pocket in full for the healthcare item or service.  Apart from the former, to the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations.  We cannot agree to limit uses/disclosures that are required by law.  

• Right to choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request if it is reasonably easy for us to do so.

• Right to inspect and request a copy of your PHI: In accordance with Federal Substance Abuse Confidentiality laws (42 CFR part 2) and HIPAA, unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your written request. We will respond to your request within 30 days or inform you of the reasons for any delay. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.  You also have a right to request a copy of such information in an electronic format and must do so in writing and you may direct us to transmit such copy directly to your designee, provided that any such choice is clear, conspicuous, and specific.

• Right to request amendment of your PHI: If you believe that there is a mistake or missing information in your record, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI.  If we approve the request for amendment, we will address the change, inform you that we did so and tell others that need to know about the change in the PHI.

• Right to find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for treatment, payment, and operations; to you, or your family; pursuant to your written authorization, made for national security purposes or to law enforcement officials or correctional facilities.  Your request can relate to disclosures going as far back as three (3) years but will not include disclosures made prior to April 14, 2003.  We will respond to your written request for such a list within 60 days of receiving it. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.  

• Right to choose someone to act for you:  You may give someone a medical power of attorney to exercise your rights and make choices about your health information.  A legal guardian / Parent can also act in that way.  We will assure that person has this authority before we take an action.

• Right to be notified in the event of a breach:  You have a right to be notified if there is a breach of unsecured PHI.

 

7. How to File a Grievance about our Privacy Practices:  

If you think we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may file a grievance with the person listed below. The procedure to file a grievance is available at any Westbrook Health Services site, but includes:  The filing must be in writing, must include the entity or individual who you believe has violated your privacy rights.  You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775. We will take no retaliatory action against you if you make such complaints.  

 

PRIVACY GRIEVANCES:  Grievances must be submitted in writing to:

Grievances Contact/Privacy Officer

Westbrook Health Services, Inc.

2121 Seventh Street

Parkersburg, WV  26101 

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