This notice describes how your treatment records may be used and disclosed and how you can get access to this information. Please review it carefully.
Information regarding your health care, including payment for health care, is protected by two federal laws; the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Under these laws, Crossroads for Women, Inc. (“Crossroads”) may not say to any person outside Crossroads that you even attend the program, nor may Crossroads disclose any information identifying you as an alcohol or drug abuser or consumer of behavioral health services, or disclose any other protected information except as permitted by federal law.
In addition, Crossroads must obtain your written consent before it can disclose information about you for payment purposes. For example, Crossroads must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Crossroads is also required to obtain your written consent before it can sell information about you or disclose information about your for marketing purposes, and Crossroads must obtain your written consent before disclosing any of your psychotherapy records. Generally, you must also sign a written consent before Crossroads can share information for treatment purposes or for health care operations. However, federal law permits Crossroads to disclose information without your written permission:
- Pursuant to an agreement with a business associate;
- For research, audit or program evaluation;
- To report a crime committed on Crossroad’s premises or against Crossroads personnel;
- To medical personnel in a medical emergency;
- To appropriate authorities to report suspected child abuse or neglect; or
- As allowed by a court order.
For example, Crossroads can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a qualified service organization/business associate agreement in place.
Before Crossroads can use or disclose any information about your health in a manner that is not described above, it must first obtain your specific written authorization allowing it to make the disclosure. Any such written authorization is valid until it expires, which may be after you leave treatment. However any authorization may be revoked by you, except to the extent Crossroads has already taken action in reliance upon it.
Under HIPAA, you have the right to request restrictions on certain uses and disclosures of your health information. Crossroads is only required to agree to your
request if you request a restriction on disclosures to your health plan for payment or health care operation purposes, and you pay for the services you receive from Crossroads yourself (out-of-pocket), unless the disclosure is otherwise required by law. In any other situation, Crossroads is not required to agree to any restrictions you request, but if it does agree, then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency.
You have the right to request that we communicate with you by alternative means or at an alternative location. Crossroads will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA, you also have the right to inspect and copy your own health information maintained by Crossroads (including your electronic health record), except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. Under HIPAA you also have the right, with some exceptions and if done in writing with the reasons for the request, to amend health care information maintained in Crossroad’s records and to request and receive an accounting of disclosures of your health related information made by Crossroads after April 14, 2003, during the six years prior to your request. You also have the right to receive a paper copy of this notice.
The Duties of Crossroads
Crossroads is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information and if there has been a breach of your information. Crossroads is required by law to abide by the terms of this notice. Crossroads reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. Any changes will be posted on the website and a paper copy will be available to you on request.
Complaints and Reporting Violations
You may complain to Crossroads if you believe that your privacy rights have been violated under HIPAA by filing a complaint in writing with its Privacy Officer. You may also complain to the Office for Civil Rights, United States Department of Health and Human Services; Substance Abuse and Mental Health Services, State of Maine; or the United States Attorney in the district where the violation occurs. You will not be retaliated against for filing such a complaint. Violation of the Confidentiality Law by a program is a crime.
For further information or to file a complaint or report a suspected violation, please contact:
Crossroads Privacy Officer
71 US Route 1, Suite E
Scarborough, ME 04074
207.773.9931; TTY 711; email@example.com
Substance Abuse and Mental Health Services, DHHS 41 Anthony Ave.
#11 State House Station
Augusta, ME 04333-0011
207-287-2595; TTY 711
Office for Civil Rights, HHS
800.368.1049 TDD 800.537.7697
United States Attorney’s Office
100 Middle Street, East Tower, 6th Floor
Portland, Maine 04101 207.780.3257; TTY 207.780.3060
800.368.1049 TDD 800.537.7697