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.
Who will follow this notice: This notice describes
Mulberry Center, Inc.'s (Mulberry Center) practices and that of:
(1) any healthcare professional authorized to enter information
into your Mulberry Center chart; (2) all employees, staff, and
other personnel of Mulberry Center; and (3) all departments of
Mulberry Center.
Information collected about you: We understand
that medical information about you and your health is personal.
We are committed to protecting medical information about you.
We create a record of care and services you receive at Mulberry
Center. We need this record to provide you with quality care and
to comply with certain legal requirements. This notice applies
to all of the records of your care generated by Mulberry Center.
Law requires us to: (1) Make sure that medical information that
identifies you is kept private; (2) give you this notice of our
legal duties and privacy practices with respect to medical information
about you; (3) follow the terms of the notice that is currently
in effect.
How we are required to disclose medical information
about you: We are required to use or disclose your health information
for the following purposes:
• When required to do so by federal, state,
or local law.
• When we believe that it is necessary to prevent serious
threat to your or another person's health & safety.
• When court ordered because you are involved in lawsuit,
dispute, or criminal conduct.
• When public health reporting is required for purposes,
including, but not limited to: the prevention or control of disease,
injury, disability, abuse, neglect, or domestic violence; reporting
of adverse effects to certain products, notifications regarding
exposure to infectious disease.
• For health oversight activities including, but not limited
to, audits, investigations, inspections, and licensure activities
necessary for the government to monitor health care systems, government
programs and compliance with various laws.
• When necessary to cooperate with court orders, to identify
or locate individuals involved in a crime, to assist or locate
victims of a crime and to assist with criminal investigations
and other law enforcement activities
• To authorized federal officials so they can provide protection
to the President or other authorized persons.
How we are permitted to disclose medical information
about you. We are permitted to use and disclose medical information
about you for the following purposes:
• For Treatment: includes providing health
information about you to a physician or other healthcare provider
who is involved with your care, whether or not they are employed
by Mulberry Center. Example: Inpatient care provider.
• For Payment: includes use or disclosure of your health
information as necessary to obtain payment for services provided
to you by Mulberry Center or another health care provider. Example:
Insurance company.
• For Healthcare operations: includes use or disclosure of
your health information for quality assessment & improvement
activities, reviewing the competence or qualifications of healthcare
professionals, conducting training, and accreditation & licensing
activities or Mulberry Center and certain, limited operations
activities of other healthcare providers and payment sources involved
in your health care.
• Sending written appointment reminders to you by mail to
your address and/or conducting appointment reminders and follow
up by telephoning your phone number.
• Notifying you of treatment options, services, and/or health-related
benefits/services that may be of interest to you.
• We may release certain limited information about you to
a friend or family member who is involved in your medical care.
We may also give information to someone who helps pay for your
care.
• We may disclose medical information about you to someone
assisting in disaster relief so that your family can be notified
about your status and location.
Special Situations when your medical information
may be used and disclosed:
• If you are a member of the armed forces,
we may release medical information about you as required by military
command authorities.
• If you are an inmate of a correctional institution or under
the custody of a law enforcement official, we may release information
about you: for the institution to provide you with health care,
to protect your or other's health and safety; or, for the safety
and security of the correctional institution.
• We may release information to Coroners, medical examiners,
and Funeral directors as necessary for them to carry out their
duties.
• We may release information about you to authorized federal
officials for intelligence, counterintelligence, and other national
security activities authorized by law.
You have the following rights regarding medical
information:
Right To Inspect And Copy
You have the right to inspect and copy medical information that
may be used to make decisions about your care. Usually this includes
medical and billing records. If you request a copy of the information,
we will charge a fee for the costs of copying, mailing, or other
supplies associated with the request. We may deny your request
to inspect and copy in certain very limited circumstances. If
you are denied access to medical information, under some circumstances
you may request that the denial be reviewed. Another licensed
health care professional chosen by Mulberry Center will review
your request and the denial. The person conducting the review
will be a person who was uninvolved with the original denial of
your request. We will comply with the outcome of the review. Instead
of providing you with a copy of your medical information, we may
provide you with a summary of your medical information maintained
by Mulberry Center. Your consent will be obtained prior to provision
of such a summary and the cost incurred in generating such a summary.
Right To Amend
If you feel that medical information we have about you is incorrect
or incomplete, you may ask us to amend the information. You have
the right to request an amendment for as long as the information
is kept by or for Mulberry Center. You must provide a written
reason that supports 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 medical
information kept by or for Mulberry Center; is not part of the
information which you would be permitted to inspect and copy;
or, is accurate and complete.
Right To An Accounting
Of Disclosures
You have a right to request an accounting of certain disclosures
of your medical information. Your request must state a time period
that may not be longer than six years and may not include dates
before April 14, 2003. Your request should indicate in what form
you want the accounting. The first accounting requested by you
in any twelve-month period will be provided free of charge. Any
subsequent accounting requests in the same twelve-month period
will be provided to you subject to your payment of a cost-based
fee. 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
medical information we use or disclose about you for treatment,
payment, or health care operations. You also have the right to
request a limit on the medical information we disclose about you
to someone who is involved in your care or the payment for your
care. 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. In your request, you must
tell us: what information you want to limit; whether you want
to limit our use, disclosure, or both; and to whom you want the
limits to apply.
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. We
will not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how or where
you wish to be contacted.
Right To A Paper Copy
Of This Notice
You have the right to a paper copy of this notice. You may ask
us to give you a copy of this notice at any time.
NOTICE: All Requests to exercise your rights
described above must be submitted in writing to the manager of
your assigned program or to Mulberry Center's Privacy Officer.
Change To This Notice
We reserve the right to change this notice. We reserve the right
to make the revised or changed notice effective for medical 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 each
of our facilities. The notice will contain on the front page,
in the top right-hand corner, the effective date. In addition,
each time you register at or are admitted to Mulberry Center for
treatment or health care services, a copy of the current notice
in effect will be available for you.
Submitting Complaints
If you believe your privacy rights have been violated, you may
file a complaint with Mulberry Center's Privacy Officer or the
Secretary of the Department of Health and Human Services. To file
a complaint with Mulberry Center, contact the Manager of your
assigned program or Mulberry Center's Privacy Officer. All complaints
must be submitted in writing. You will not be penalized for filing
a complaint.
Other Uses Of Medical
Information
Other uses and disclosures of medical information not covered
by this notice or other laws that apply to Mulberry Center will
be made only with your written permission. If you provide us permission
to use or disclose medical information about you, you may revoke
that permission, in writing, at any time. If you revoke your permission,
we will no longer use or disclose medical information about you
for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already
made with your permission, and we are required to retain our records
of that care that we provided to you.
For Additional Information
If you want more information about our privacy practices, wish
to exercise your rights as described by this Notice or have other
questions or concerns, please contact: Mulberry Center, Inc.,
c/o Privacy Officer, 414 S.E. Fourth Street, Evansville, Indiana
47713, TELEPHONE: (812) 423-4700.
