For a PDF of this document, click here.

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.

Effective Date: April 14, 2003

Revision Date: February 1, 2008

I. Who Will Comply With This Notice?
This notice will be followed by Wellplace, Inc., a subsidiary of Pioneer Behavioral Health.

II. Our Commitment Regarding Your Confidential Health Information
In order to provide you with the highest quality of care and to comply with various laws, we maintain a record of the services you receive from us. Your record contains personal information regarding your health care and payment for your health care. We understand that your health information is personal, and we are fully committed to protecting and enforcing your privacy rights.

This notice outlines our obligations with regard to using or disclosing your confidential health information and describes your rights to access such information.

By law, we are required to ensure that your confidential health information remains private. We also are required to provide you with a copy of this notice and comply with the terms of the notice that is currently in effect.

III. How We May Use or Disclose Your Confidential Health Information

A. For Treatment
We may use or disclose your confidential health information to provide you with health care treatment or services. For example, physicians, physician’s assistants, therapists, counselors, nurses, or other clinical staff members will record information in your medical record to diagnose your condition and determine the best course of treatment for you. Those individuals will work to provide you with the highest quality of care. We also may provide other health care professionals or subsequent health care providers with a copy of your medical records to assist them in treating you after you leave our care.

B. For Payment
We may use or disclose your confidential health information so that we may bill for services rendered and collect payment from you, an insurance company, or a third party, such as Medicare or Medicaid or an employee assistance program. For example, we may send a bill to your health plan, such as a health insurer, which may include information that identifies you, your diagnosis, treatments received, and supplies utilized. We also may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine your eligibility to receive the treatment.

C. For Health Care Operations
We may use or disclose your confidential health information for the operations of our health care businesses. For example, clinicians, risk management staff, and members of our quality assurance teams may use your health information to evaluate the care and outcomes you received, as well as to assess the competency of our caregivers. Our health care operations are aimed at continually improving the quality and effectiveness of the health care and services we provide.

D. For Appointment Reminders and Treatment Alternatives
We may contact you for appointment reminders or to tell you about possible treatment options, alternatives, health-related benefits, or other services that may be of interest to you.
E. To Prevent a Threat to Health, Safety, or Welfare
We may disclose your confidential health information to the appropriate authorities if, in our professional or clinical judgment, we believe you are the victim of abuse, neglect, domestic violence, or other crimes, or to avert a threat to the health and safety of you or others.

F. To Our Business Associates
We receive some services through contracts with third-party business associates. For example, we may utilize outside vendors to provide medical transcription or billing collection services. When we use such services, we may disclose your confidential health information to the business associates so that they can perform the functions on our behalf. To protect your privacy rights, we contractually require that the business associates appropriately safeguard your confidential information.

G. For Use in a Facility Directory or Census Report
We may use your name, location in our facility, and general condition for an internal directory, census report, or similar patient-listing purposes.

H. For Communications With Your Family or Caregivers
Unless you provide us with a written objection, we may, in our best professional judgment, disclose your confidential health information to a family member or caregiver, if such information is relevant to that person’s direct involvement in your care or payment for your care. Such disclosures may be made to your family member, legal guardian, another relative, personal friend, or any other individual you identify to us.

I. For Research Purposes
We may disclose your confidential health information to researchers when an institutional review board has approved their research. The institutional review board will have reviewed the research proposal and established protocols to ensure the privacy of your health information.

J. In Lawsuits and Legal Disputes
If you are involved in a lawsuit or other legal dispute, we may disclose your confidential health information in response to an order of a court or tribunal. We may also disclose your confidential health information in response to a subpoena, warrant, discovery request, or other similar legal process by someone else involved in the matter, though we will attempt to obtain your written authorization prior to doing so.

K. To Funeral Directors or Coroners
We may disclose your confidential health information to funeral directors or coroners, consistent with applicable laws, in order to enable them to carry out their duties, such as identifying a deceased individual or determining a cause of death.

L. To the Food and Drug Administration (FDA)
We may disclose your confidential health information to the FDA, if such disclosure is related to adverse effects or events with respect to food, drugs, supplements, products or product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.

M. To Workers’ Compensation Agencies
We may disclose your confidential health information, consistent with applicable laws, when necessary to comply with laws relating to workers’ compensation or other similar employment-related programs established by law.

N. For Health Oversight Activities
We may disclose your confidential health information to health oversight agencies for authorized activities, which may include audits, investigations, and inspections related to our licensure, insurance, and accreditation status. These activities monitor compliance with government programs, contractual agreements, licensure and accreditation standards, and laws and regulations.

O. To the U.S. Department of Health and Human Services (DHHS)
We must disclose your confidential health information to DHHS upon request, as necessary to determine our compliance with the government’s standards and regulations.

P. For Matters of Public Health
We may disclose your confidential health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Such cases may include disclosures necessary to prevent or control diseases, to report possible abuse or neglect, or to notify individuals of product defects and recalls.

Q. To Correctional Institutions
If you are an inmate of a correctional institution or are under the custody of a law enforcement agency, we may disclose your confidential health information to the institution when necessary for your health or the health and safety of others.

R. For Law Enforcement Purposes
We may disclose your confidential health information for law enforcement purposes, including in response to a court order, subpoena, warrant, or other similar legal process, to identify or locate a suspect, fugitive, material witness, to report criminal conduct at our facility, or to report an injury or death we believe might have been a result of criminal activity.

S. To Authorities for Military, National Security or Intelligence Purposes
We may disclose your confidential health information, if required, to military authorities or federal officials for authorized activities related to military, intelligence, counter-intelligence, or other national security matters.

T. Other Uses and Disclosures Not Described Above
For all other uses and disclosures, the facility will obtain your prior written authorization. You have the right to revoke such authorizations, pursuant to the terms found on the facility’s authorization form.

IV. Your Rights
With respect to your confidential health information, you have the following rights:

A. Right to Inspect and Copy
You have the right to inspect and have copied your confidential health information. To inspect and copy your confidential health information, you must submit your request in writing to the facility’s Medical Records Department. If you request a copy of the information, we may charge a reasonable cost-based fee for the copying and mailing per your request. Subject to applicable laws, we may deny your request to inspect and copy if, in our professional judgment, we determine that it would be detrimental to your care or otherwise harmful to you or others or if denial is permissible under other applicable laws.

B. Right to Request an Amendment
If you feel your confidential health information is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing to the facility’s Medical Records Department. In addition, you must provide a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing, does not include a reason to support the request, if it would be detrimental for your care or otherwise harmful to you or others, or if the information is correct and complete. The facility’s clinical supervisor will review all such requests.

C. Right to Accounting of Disclosures
You have the right to request a list of accounting for disclosures of your confidential health information that we made. To request this accounting of disclosures, you must submit your request in writing to the facility’s Medical Records Department. Your request must state a specific time period for when the disclosures were made. We will provide you with the accounting in the manner you designate in writing, or notify you of the reasons why we are unable to provide such accounting. Please be aware that we will not provide an accounting of all disclosures that were made, such as those disclosures made (a) prior to April 14, 2003; (b) for treatment purposes; (c) for payment purposes; (d) for health care operations; (e) pursuant to your written authorization; or, (f) as part of the facility’s directory or census reports.

D. Right to Request Restrictions
You have the right to request a restriction or limitation on the way we use or disclose your confidential health information. Your request must be submitted in writing to the facility’s Medical Records Department, and it must state the specific information you want restricted and how you want the restriction to occur. We are not required to agree to your request for restrictions if it is not feasible for us to comply, if we believe it will negatively impact the care we provide you, or if the restriction will prevent us from providing emergency treatment. If we do agree, we will comply with your request. The facility’s clinical supervisor will review all such requests.

E. Right to Request Confidential Communications
You have the right to request that we provide confidential communications to you. You may ask us to share information with you in a manner or location of your choice. For example, you could request that we send your information to an address other than your home address or that all communications be made via mail. To request confidential communications, you must make your request in writing to the facility’s Medical Records Department. You do not need to provide reasons for your request, and we will attempt to accommodate all reasonable requests.

F. Right to Obtain a Paper Copy of This Notice
You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please submit a written request to the facility’s Medical Records Department. Please be aware that this notice is available and posted at all of our facilities and on the facilities’ websites.

V. Changes to This Notice
We reserve the right to modify the provisions of this notice and to make the new notice effective for all confidential health information we maintain prior to the effective date of the new notice. If we modify this notice, we will post the new notice in our facilities and on our facilities’ websites.

VI. Questions or Complaints
If you want more information about our privacy practices, have questions or concerns, or would like to file a privacy complaint, you may contact our Corporate Compliance Officer at (978) 536-2777. You also may submit a complaint to the Office of Civil Rights (OCR) of the DHHS. We will not retaliate against you in any way if you choose to file a complaint about our privacy practices, nor will it affect your rights or status as a patient with us.