Understanding Your Counseling/Mental Health Record Information

Each time you visit a counseling or mental health agency, hospital, a physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your family and/or health history, current symptoms, test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to as your counseling or medical record, serves as the following:

• Basis for planning your care and treatment.
• Means of communication among the agencies and professionals who may contribute to your care.
• Legal document describing the care that you received.
• Means by which you or a third-party payer can verify that you actually received the services billed for.
• Source of information for public health officials charged with improving the health of the regions they serve.
• Tool to assess the appropriateness and quality of care that you received.
• Tool to improve the quality of counseling and/or mental health care and achieve better patient outcomes.

Understanding what is in your counseling records and how your information is used helps you to-

• Ensure its accuracy and completeness.
• Understand who, what, where, why, and how others may access your personal information.
• Make informed decisions about authorizing disclosure to others.
• Better understand the health information rights detailed below.

Your Rights under the Federal Privacy Standard

Although your records are the physical property of the agency or provider who completed it, you have the following rights with regard to the information contained therein:

• Request restriction on uses and disclosures of your information for treatment, payment, and quality improvement processes. The right to request restriction does not extend to uses or disclosures permitted or required under the following sections of the federal privacy regulations: § 164.502(a)(2)(i) (disclosures to you), 164.510(a) (for facility directories, but note that you have the right to object to such uses), or 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory child abuse reporting. In those cases, you do not have a right to request restriction. The consent to use and disclose your individually identifiable information provides the ability to request restriction. We do not, however, have to agree to the restriction. If we do, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is reasonable, we must grant the alternate communication request. You may request restriction or alternate communications on the consent form for treatment, payment, and health care operations.
• Obtain a copy of this Notice of Information Practices. Although we have posted a copy in the lobby of our facilities and on our website, you have a right to a hard copy upon request.
• " Inspect and copy your information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
• Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated from the rest of your counseling record.
• Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
• Protected health information ("PHI") that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C. § 263a, to the extent that giving you access would be prohibited by law.
• Information that was obtained from someone other than a health care provider under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.

In other situations, we may deny you access, but if we do, we must provide you a review of our decision denying access. These "reviewable" grounds for denial include the following:

• A licensed healthcare professional, such as your therapist, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or another person.
• PHI makes reference to another person (other than a health care provider) and a licensed health care provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
• The request is made by your personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that giving access to such personal representative is reasonably likely to cause substantial harm to you or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review.

If we grant access, we will tell you what, if anything, you have to do to get access. We reserve the right to charge a reasonable, cost-based fee for making copies.

• Request amendment/correction of your health information. We do not have to grant the request if the following conditions exist:
• We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.
• The records are not available to you as discussed immediately above.
• The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom you identify to us that you want to receive the corrected information.

• Obtain an accounting of non-routine uses and disclosures, those other than for treatment, payment, and health care operations. We do not need to provide an accounting for the following disclosures:
• To you for disclosures of protected health information to you.
• For the facility directory or to persons involved in your care or for other notification purposes as provided in § 164.510 of the federal privacy regulations (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of the your location, general condition, or death).
• For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
• To correctional institutions or law enforcement officials under § 164.512(k)(5) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
• That occurred before April 14, 2003.
• We must provide the accounting within 60 days. The accounting must include the following information:
• Date of each disclosure.
• Name and address of the organization or person who received the protected health information.
• Brief description of the information disclosed.
• Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.

• Revoke your consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.

Our Responsibilities under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the following measures:

• Maintain the privacy of your counseling information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
• Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable counseling information that we collect and maintain about you.
• Abide by the terms of this notice.
• Train our personnel concerning privacy and confidentiality.
• Implement a sanction policy to discipline those who breach privacy/ confidentiality or our policies with regard thereto.
• Mitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

How to Get More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact the Privacy Officer who is also the Director of Quality Improvement at (727) 835-4166 or (863) 701-1177.

Examples of Disclosures for Treatment, Payment, and Quality Improvement

If you give us consent, we will use your information for treatment.

Example: A therapist or a counselor, or another member of your team will record information in your record so that an appropriate course of intervention for you can be developed. The primary therapist or counselor will develop a service plan and document what he or she expects other members of the team to do on your behalf. Those other members will then document the actions they took and their observations. In that way, the primary therapist or counselor will know how you are responding to the interventions.

YFA will also provide if necessary and with your permission or as otherwise required by law copies of your records to assist other agencies and/or professionals in treating you once we are no longer providing services to you.

If you give us consent, we may use your information for payment.

Example: We may send a bill to you or to a third-party payer.

If you give us consent, we will use your counseling information for quality improvement purposes.

Example: Members of the clinical staff, the risk manager or quality improvement manager, or members of the peer review team may use information in your record to assess the care and outcomes in your case regarding services that has been provided to you. We will use this information in an effort to continually improve the quality and effectiveness of the services that we provide.

• Business associates: We provide some services through contracts with business associates. Examples include Iron Mountain, a record storage company. We are required by law to maintain your record for seven years from the time your case is closed with us. Consumer records are maintained on YFA premises for two years after services are completed or terminated and than sent to Iron Mountain for storage and protection. To protect you information, however, we require Iron Mountain to appropriately safeguard your information.
• Notification: We may use or disclose information to notify or assist in notifying a family member, a personal representative, or another person responsible for your care, your location, and general condition.
• Communication with family: Unless you object, clinical professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify, information relevant to that person's involvement in your care.
• Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
• Marketing/continuity of care: We may contact you to provide appointment reminders or information about treatment alternatives or other related benefits and services that may be of interest to you.
• Fundraising: We may contact you as a part of a fundraising effort. You have the right to request not to receive subsequent fundraising materials.
• Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, disability or in the course of a criminal investigation by law enforcement.
• Law enforcement: We may disclose information for law enforcement purposes as required by law or in response to a valid subpoena.
• Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more consumers of service, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.
• The federal Department of Health and Human Services ("DHHS"): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.
• Child Abuse Reporting: We are required by law to report suspected cases of child abuse and/or neglect to the Florida child abuse hotline.
• Electronic database: Information about you will be entered into a database if this activity is required by the governmental funding source or by the agency. This information is available only to those with a need to know and is safeguarded with password protection. This information is used in compiling statistical information about those we serve and is considered confidential.

George Magrill, President and CEO
Effective Date: April 14, 2003