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.

Disclosure of Use Information Within Shorehaven. The Federal Health Insurance Portability and Accountability Act (HIPAA, at 45 CFR Parts 160 and 164 ) requires that all persons given any Health services, including initial evaluation, receive a notice of our privacy policies (as contained in this document) regarding the storage, use, and transmission of their Protected Health Information. HIPAA sets guidelines for how a clinic, such as Shorehaven, must maintain, store, and transmit this information and must adopt procedures to protect confidentiality. In actuality, Wisconsin law and Shorehaven policies have been as stringent as HIPAA and often even more protective of your confidentiality all along.

• This form is a general HIPAA disclosure of the use of information at Shorehaven and it does not permit your information to be sent to any other person except for the purposes of billing and collection and for treatment-related operations within the clinic. However, certain entities set forth in Wisconsin Statues Chapter 51, such as the clinic licensing division, Medicaid auditors, quality auditors, the County coroner, and other oversight agencies, who are bound to maintain a high level of confidentiality, may audit our files for certain statutory reasons, such as quality audits or funding audits or other reasons.
• When we transmit information to insurance companies, they are bound by the same rules.
• When we store information, we keep it in file folders which are stored in file cabinets which are locked at night and kept in a locked office or we keep computer files in password protected secure servers.
• Our computer files are password protected and, when necessary, firewall protected.
• Our electronic communications are sent to secure sites or, when we communicate with you by e-mail, your permission is required before non-encrypted communications take place.
• Our staff has been trained in HIPAA confidentiality procedures.

Disclosures Within Shorehaven. Your signature below indicates your are aware of the collection and storage of Protected Health Information, especially, Treatment, Payment, and Other Health Care information and to its use for the purposes of treatment, billing and collection procedures, and within the staff of Shorehaven as detailed below. Consent is not required to maintain and share information for these purposes. These disclosures within the clinic for treatment, payment, and other purposes is termed "routine" disclosure.

Purpose. The purpose or need for maintaining and disclosing this information within the clinic is to help our clients by sharing information within the clinic and with its business associates (for example, a billing service or company accountant) in these ways:

1. Treatment: The need for information for Treatment includes, but is not limited to, calling to confirm appointments; contacting you with information about services of interest; aiding in diagnosis, assessment, recommendations, and treatment planning; consultation between staff members at Shorehaven as required by law, such as consultation between interns and supervisors or between licensed staff and clinical consultants; coordination between providers who jointly provide services to you within Shorehaven; and coordination with support staff who assist in maintaining records and in billing. So, for example, required consulting within SBH allows us to have a treatment team so you receive the best help.
2. Payment: The need for information for Payment includes, but is not limited to determinating eligibility for coverage, billing, claims management, collection activities, claims status, authorizations for treatment, and utilization review, including transmission of treatment plans to the insurer and following the insurer's procedures for authorization. For example, we need to send name, address, session dates, diagnosis, and procedure codes, and selected other information for the insurance company to pay for services.
3. Other Health Care Operations: The need for information for other operations includes, but is not limited to, medical, administrative, educational, legal, or vocational planning or services undertaken on patient's behalf; quality assessment and utilization review; medical reviews; auditing; coroner functions; business planning and administrative services; internal consultation between staff members such as to plan services in emergencies, defense of lawsuits, administrative hearings; fund-raising. In this case, staff members other than your primary therapist may interact with you, or regarding you, and may generate documentation which will be part of your record maintained at Shorehaven. You may choose to permit a case manager, probation officer, clergy, friend, or family member sit in on services.
   
   
   
   
   

Disclosures with Consent. A separate consent form, known as Authorization for Disclosure, will be completed specifically permitting exchange of information with an insurer/third party payer or other persons . An Authorization for Disclosure is good for 15 months and you may revoke it in writing before it expires. We will then stop disclosing information to the parties on that form except we cannot take back the disclosures we already made in reliance upon your original consent. A disclosure with your permission is termed a "non-routine" disclosure.

Storage of records is for seven years from the conclusion of services. Disposal is by shredding. This form has no expiration date unless revoked or amended.

Disclosure of Protected Information Without Consent. Federal law (42 CFR Part 2, 45 CFR 160 & 164), State law (Chapter 51, HFS 61, HFS 75, HFS92, HFS94), and various other codes and ethical principles also require careful safeguarding of your information. We are required by law to keep detailed records. But we will only disclose information about you to persons not associated with Shorehaven under a few very limited circumstances: 1) with your specific written permission (known as "non-routine" disclosure), 2) in response to certain court orders and judicial subpoenas, 3) in the case of child or elder abuse or neglect reports or in the case of the duty to report clients who may be dangerous to self or others, 4) in the case of confidential audits by governmental, public health, insurance and other oversight programs, 5) in emergency situations, such as sending a patient to the hospital or calling the paramedics, when we will disclose the minimum information necessary to accomplish the goal of effectively helping the patient to receive appropriate treatment.

Private Psychotherapy Notes. Therapist private Psychotherapy Notes are not part of the clinic file and will not be disclosed to any entity. For example, interns make detailed notes to discuss their work in supervision for learning purposes. Psychotherapy notes are destroyed at the discharge of the case or when they no longer are needed for supervisory or record-keeping purposes.

Policies. Because you may request the privacy policies notice of providers, we have provided this document covering all the policies. We may change this notice and when we do we will post copies in the waiting room and hand out copies to active clients.

• Revocation. This consent may be revoked by written notice at any time except to the extent the provider of information has already acted upon it.
• Restriction. You may request a restriction on the information to be released and its use. The Shorehaven Authorization for Disclosure of Confidential Information/Records can be used for this purpose. You may also restrict the use of information within Shorehaven by submitting a written request which clearly states which information is restricted. Doing so or deciding not to sign this document may, however, lead Shorehaven to determine that services cannot in good faith or ethically be provided. We do not have to agree to the restrictions upon internal use of protected information.
• History of Disclosures. You may request a listing of the history of any "non-routine" disclosures we have made, that is, disclosures requiring the Authorization for Disclosure of Confidential Information/Records form, going back 6 years, but not disclosures before April 14, 2003. These disclosures are made with care to follow state and federal guidelines for releasing information. If you request this history, we will have 60 days to prepare it. Only the first such history is without charge, and the cost of future lists will be based upon the cost of assembling the information.
• Follow-Up. When an AODA patient completes treatment or transfers, state law (HFS 75.03(19)) requires follow-up contact.
• Fees for Copying. You have a right to request in writing a paper copy of your record (other than psychotherapy notes). A uniform and reasonable fee may be charged for a copy of records, and its transmission, which fee may be reduced or waived in accordance with agency policy. Shorehaven will have 21 days to respond to a request for records.
• Amending Records. You have a right to inspect the record and usually, where you find errors, to amend the record (by making a written request for permission to make additions and amendments), although state and federal law provides a few restrictions on this right when restrictions are judged to be in your best interests. Note: we cannot amend information we did not create in the first place, such as records from another provider. Psychotherapy notes are not included in this right to amend records. Submit a written request to amend records and your reasons to our Privacy Officer. If we restrict your access to information, you may ask us to have a consultant on our staff review the denial and you will receive a written explanation of the reason and your right to review of our decision. You may also ask for a summary or explanation of the information, as long as you agree to the fee for that service. If you want to amend the file, we'll let you know if the amended information is accepted and we'll send the change with any copies of the file which go out when you ask us to disclose the file. If it's not accepted, we'll inform you, and you may offer your disagreement, which will become part of the record; and you can have our complaint officer review the process.
• Transport of Data. We may need to transport documents from a home visit or satellite office and we will do so with care to protect your confidentiality.
  
  
  
  
  
• Electronic Transmissions. When we send a fax or e-mail, we attempt to be sure the receiver of the information is entitled to it per your release. We attempt to limit communications about you to secure web sites or secure e-mail unless we have your permission to transmit via unsecured e-mail, and then only to you. If you receive this form via e-mail or website, we will make a paper copy available as well.
• Complaints. You may bring complaints without retaliation to Don Rosenberg, President, Shorehaven Behavioral Health, Inc., 3900 W. Brown Deer Road, Suite 200, Brown Deer, WI 53209, (414) 540-2170. The Secretary of the U.S. Dept. of Health and Human Services also receives complaints about believed privacy violations. The HHS Office For Civil Rights (OCR) is responsible for enforcement and is supposed to provide assistance to help providers and others comply with the rule. Their informative website is found at http://www.hhs.gov/ocr/hippa

This authorization form is intended to be in conformance with Section 51.30(4)(d), Wisconsin Statues, and Sections HFS 92.03(3)(d), 92.05, and 92.06., Wisconsin Administrative codes, and sections 49.53, 51.30(2), and 146.82 Wisconsin Statutes, and 42 CFR Part 2 and 45 CFR 160 and 164 of Federal Regulations.

Your signature indicates you received a copy of this form and understand your privacy rights, and permit the use of Psychotherapy Notes.

Every adult must sign a separate HIPAA form and MUST be given the form at the first service date. Documentation of attempts to acquire general HIPAA consent should be in a progress note if this form was not signed at initial contact. This notice became SBH policy 5/25/06. (Rev 6/5/06)