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.
Sierra at Southlake will be referred to in this Notice of Privacy Practices (“Notice”) as “Facility.” This Notice is given to you by an Acadia Healthcare Facility to describe the ways in which Facility may use and disclose your medical information (called “protected health information” or “PHI”) and to notify you of your rights with respect to PHI in the possession of Facility. Facility protects the privacy of PHI, which also is protected from disclosure by state and federal law. In certain circumstances, pursuant to this Notice, patient authorization or applicable laws and regulations, PHI can be used by Facility or disclosed to other parties. Below are categories describing these uses and disclosures, along with some examples to help you better understand each category.
Uses and Disclosures for Treatment, Payment and Health Care Operations
Facility may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining written authorization from you.
FOR TREATMENT: Facility may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities at another healthcare facility. These types of uses and disclosures may take place between physicians, nurses, technicians, students, and other health care professionals who provide you health care services or are otherwise involved in your care. For example, if you are being treated by a primary care physician, that physician may need to use/disclose PHI to a specialist physician whom he or she consults regarding your condition, or to a nurse who is assisting in your care.
FOR PAYMENT: Facility may use and disclose PHI in order to collect payment for the health care services provided to you. For example, Facility may need to give PHI to your health plan in order to be reimbursed for the services provided to you. Facility may also disclose PHI to their business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. Facility may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans.
FOR HEALTH CARE OPERATIONS: Facility may use and disclose PHI as part of their operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive and the performance of our staff in caring for you. Other activities include hospital training, underwriting activities, compliance and risk management activities, planning and development, and management and administration. Facility may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants, and others for review and learning purposes. These disclosures help make sure that Facility is complying with all applicable laws, and are continuing to provide health care to patients at a high level of quality. Facility may also disclose PHI to other health care facilities plans for certain of their operations, including their quality assessment and improvement activities, credentialing and peer review activities, and health care fraud and abuse detection or compliance, provided that those other facilities and plans have, or have had in the past, a relationship with the patient who is the subject of the information.
FOR SHARING PHI AMONG FACILITY AND PROFESSIONAL STAFF: Facility works together with physicians and other care providers on their professional staff to provide medical services to you when you are a patient at an Acadia Healthcare Facility. Facility and members of their respective professional staff will share PHI with each other as needed to perform their treatment, payment and health care operations activities.
OTHER USES AND DISCLOSURES FOR WHICH AUTHORIZATION IS NOT REQUIRED: In addition to using or disclosing PHI for treatment, payment and health care operations, Facility may use and disclose PHI without your written authorization under the following circumstances:
AS REQUIRED BY LAW AND LAW ENFORCEMENT: Facility may use or disclose PHI when required by law, Facility also may disclose PHI when ordered to in a judicial or administrative proceeding, in response to subpoenas or discovery requests, to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, its location or victims, or the identify, description or location of a person who committed a crime, or for other law enforcement purposes.
FOR PUBLIC HEALTH ACTIVITIES AND PUBLIC HEALTH RISKS: Facility may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence, reactions to medications or product defects or problems, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.
FOR HEALTH OVERSIGHT ACTIVITIES: Facility may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws.
CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS: Facility may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.
ORGAN, EYE, AND TISSUE DONATION: Facility may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation.
RESEARCH: Under certain circumstances, Facility may use and disclose PHI for medical research purposes.
TO AVOID A SERIOUS THREAT TO HEALTH OR SAFETY: Facility may use and disclose PHI to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, Facility may disclose health information about you in response to a court or administrative order.
SPECIALIZED GOVERNMENT FUNCTIONS: Facility may use and disclose PHI of military personnel and veterans under certain circumstances, and may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations.
WORKERS’ COMPENSATION: Facility may disclose PHI to comply with workers’ compensation or other similar laws that provide benefits for work-related injuries or illnesses.
HEALTH-RELATED BENEFITS AND SERVICES; LIMITED MARKETING ACTIVITES: Facility may use and disclose PHI to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs.
Disaster Relief: Facility may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
DISCLOSURES TO YOU OR FOR HIPAA COMPLIANCE INVESTIGATIONS: Facility may disclose your PHI to you or to your personal representative, and are required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Facility must disclose your PHI to the Secretary of the U.S. Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)
Uses and Disclosures to Which You May Object:
You may object to the following uses and disclosures of PHI that Facility may make:
PATIENT DIRECTORIES: Your information may be included in a patient directory that is available only to those individuals whom you have identified as contacts during your hospital stay. You will receive a unique patient code that can be provided to these contacts.
Other Uses and Disclosures of PHI for Which Authorization Is Required:
Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which you have the limited right to revoke in writing.
REGULATORY REQUIREMENTS: Facility is required by law to maintain the privacy of your PHI, to provide individuals with notice of their legal duties and privacy practices with respect to PHI, and to abide by the terms described in this Notice. Facility reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all of the PHI it maintains. Before Facility makes an important change to its privacy policies, they will promptly revise this Notice and post a new Notice in registration and admitting areas. You have the following rights regarding your PHI:
You may request the Facility restrict the use and disclosure of your PHI. Facility is not required to agree to any restrictions you request, but if the entity does so it will be bound by the restrictions to which it agrees except in emergency situations.
You have the right to request that communications of PHI to you from Facility be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be in writing and sent to the Privacy Officer. Facility will accommodate your reasonable requests without requiring you to provide a reason.
Generally, you have the right to inspect and copy your PHI in the possession of Facility if you make a request in writing to the Facility’s Medical Records Department. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), Facility will inform you of the extent to which your request has or has not been granted. In some cases, Facility may provide you a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you request copies of your PHI or agree to a summary of your PHI, Facility may impose a reasonable fee to cover copying, postage, and related costs. If Facility denies access to your PHI, it will explain the basis for denial and your opportunity to have the denial reviewed by a licensed health care professional (not involved in the initial denial decision) designated as a reviewing official. If Facility does not maintain the PHI you request, if it knows where that PHI is located it will tell you how to redirect your request.
If you believe that your PHI maintained by Facility contains an error or needs to be updated, you have the right to request that the entity correct or supplement your PHI. Your request must be made in writing to the local Medical Records Department and it must explain why you are requesting an amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Facility will inform you of the extent to which your request has or has not been granted. Facility generally can deny your request if your request relates to PHI: (i) not created by Facility; (ii) that is not part of the records Facility maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, Facility will give you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) submit a request that any future disclosures of the relevant PHI be made with a copy of your request and Facility’s denial attached, if you do not file a statement of disagreement; and (iii) complain about the denial.
You generally have the right to request and receive a list of disclosures of your PHI Facility has made during the six (6) years prior to your request (but not before April 14, 2003). The list will not include disclosures (i) for which you have provided a written authorization; (ii) for treatment, payment, and health care operations; (iii) made to you; (iv) for an Facility patient directory or to persons involved in your health care; (v) for national security or intelligence purposes; (vi) to correctional institutions or law enforcement officials; or (vii) of a limited data set. You should submit any such request to the Privacy Officer, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Facility will respond to you regarding the status of your request. The entity will provide the list to you at not charge, but if you make more than one request in a year you will be charged $25.00 for each additional request.
You have the right to receive PHI in an electronic format, if electronic medical records are in use in the facility.
You have the right to receive a paper copy of this notice upon request even if you have agreed to receive this notice electronically. To obtain a paper copy of this notice, please contact the Privacy Officer (Contact information below).
You have the right to receive notice in the event of a breach of confidentiality.
You have the right to opt out of all communications from our company including fundraising.
You have the right to restrict disclosures of PHI to health plans if you have paid for services out of pocket in full.
CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of the new notice on our website. The notice will contain the effective date on the second page, in the bottom right-hand corner.
You may complain to Facility if you believe your privacy rights with respect to your PHI have been violated by contacting Facility’s Privacy Officer and submitting a written complaint. To reach the Facility for any reason associated with this Notice, please write or call:
Sierra at Southlake
640 W Southlake Blvd
Southlake, TX 76092
Facility will not penalize you or retaliate against you for filing a complaint regarding their privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services at 200 Independence Avenue, S.E., Washington, DC
If you have any questions about this notice, please contact the facility as listed above or Acadia Healthcare’s Compliance Ethics Hotline: 1 (888) 610-6593 or click here for the Acadia Compliance Alert Form.