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NOTICE DESCRIBES HOW PERSONAL AND MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our Privacy Commitment to You
We care about your privacy. The information we collect about you is
private. We are required to give you a notice of our privacy
practices. Only people who have both the need and the legal right may
see your information. Unless you give us permission in writing, we
will only disclose your information for purposes of treatment,
payment, business operations or when we are required by law to do so.
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Treatment
We may disclose medical information about you to coordinate your
health care. For example, between your case manager and the CMH
physician. |
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Payment
We may use and disclose information so the care you get can be
properly billed and paid. For example, sending billing information to
a health insurance plan. |
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Business Operations
We may need to use and disclose information for our business
operations. For example, we may use information to review the quality
care you receive. |
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Exceptions
For certain kinds of records, your permission may be needed even for
release for treatment, payment and business operations. |
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As Required By Law
We will release information when we are required by law to do so.
Examples of such releases would be for law enforcement or national
security purposes, subpoenas or other court orders, communicable
disease reporting, disaster relief, review of our activities by
government agencies, to avert a serious threat to health or safety or
in other kinds of emergencies. |
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With Your
Permission If you give us permission in writing, we may
use and disclose your personal information. If you give us permission,
you have the right to change your mind and revoke it. This must be in
writing, too. We cannot take back any uses or disclosures already made
with your permission.
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Privacy Rights
You have the following rights regarding the
health information that we have about you. Your requests must be made
in writing to North Country Community Mental Health Authority.
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Your Right to
Inspect and Copy In most cases, you have the right to
look at or get copies of your records. You may be charged a fee for
the cost of copying your records. |
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Your Right to Amend
You may ask us to change your records if you feel that there is a
mistake. We can deny your request for certain reasons, but we must
give you a written reason for our denial. |
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Your Right to a
List of Disclosures You have the right to ask for a list
of disclosures made after April 14, 2003. This list will not include
the times that information was disclosed for treatment, payment, or
health care operations. The list will not include information provided
directly to you or your family, or information that was sent with your
authorization. |
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Your Right to
Request Restrictions on Our Use or Disclosure of Information
You have the right to ask for limits on how your information is used
or disclosed. We are not required to agree to such requests. |
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Your Right to
Request Confidential Communications You have the right
to ask that we share information with you in a certain way or in a
certain place. For example, you may ask us to send information to your
work address instead of your home address. You do not have to explain
the basis for your request.
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Changes to
this Notice
We reserve the right to revise this notice. A revised notice will be
effective for medical information we already have about you as well as
any information we may receive in the future. We are required by law
to comply with whatever notice is currently in effect. If changes are
material, a new notice will be mailed to you before it takes effect.
How to Use Your Rights Under This Notice
If you want to use your rights under this notice, you may call us or
write to us. If your request to us must be in writing, we will help
you prepare your written request if you wish.
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Complaints to the
Federal Government If you believe that your privacy
rights have been violated, you have the right to file a complaint with
the federal government. You may write to:
Office of Civil Rights
Dept. of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 866-627-7748
TTY: 866-788-4989
Email: ocrprivacy@hhs.gov
You will not be penalized for
filing a complaint with the federal government.
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Complaints and
Communications to Us If you want to exercise your rights
under this notice or if you wish to communicate with us about privacy
issues or if you wish to file a complaint, you can write to:
Privacy Officer
North Country CMH
PO Box 220
Bellaire, MI 49615
Phone: 231-533-8619
You will not be penalized for
filing a complaint.
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Copies of
this Notice
You have the right to receive an additional copy of this notice at any
time. Even if you have agreed to receive this notice electronically,
you are still entitled to a paper copy of this notice. Please call or
write to us to request a copy.
PRIVACY NOTICE
Phone: 231-533-8619
Fax: 231-533-6973
Email: jansmith@norcocmh.org
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