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.

Who Will Follow This Notice

This Notice describes National Mental Health Association of Greater Los Angeles [“MHA”] practices and that of:

• All employees, staff and other MHA personnel,

• Any individual volunteer or member of a volunteer group we allow to help you while you are in our facility or program.

Our Pledge to You Regarding Your Medical Information

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive through our facility or programs. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by our program(s). As required and when appropriate, we will ensure that the minimum necessary information is released in the course of our duties.

This Notice tells you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations regarding the use and disclosure of medical information.
The law requires us to:

• Keep your medical information, known as “protected health information” or “PHI,” private;

• Give you this Notice of our legal duties and privacy practices with respect to your PHI; and

• Follow the terms of the Notice that is currently in effect.

How We May Use and Disclose Your Protected Health Information

The following categories describe the different ways that we may use and disclose your protected health information. For each category of uses or disclosures we will explain what we mean, and try to give some examples. Obviously not every use or disclosure in a category can be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We create a record of the services and treatment you receive in our facility or program. We may use and disclose your PHI in order to provide you with services and medical treatment. We may disclose your PHI to doctors, nurses, personal service coordinators (PSCs) and other MHA staff members such as financial planners, employment or community integration specialists, medical or social work students or other personnel who are involved in your care at our facility or program. For example, a doctor treating you for a chemical imbalance may need to know if you have problems with your heart because some medications affect your blood pressure. We may share your PHI in order to coordinate the different things you need, such as prescriptions, blood pressure checks and lab tests, and to determine a correct diagnosis. We may also disclose your PHI to healthcare professionals outside our facility or program, but only if they are directly involved in your care or treatment [such as your therapist at the Department of Mental Health, or your pharmacist or other similar persons], and it is for the coordination and management of your care.

For Payment: We may use and disclose your PHI in order to get paid for the services we provide to you. For example, we may need to give Medi-Cal, the Department of Mental Health or your private insurance plan information about services, medication or other treatment you receive through us so that they will pay us. We may also tell them about treatment you are proposing that you receive, in order to obtain prior approval or to determine if they will cover the cost of the treatment.

For Health Care Operations: We may use and disclose your PHI to carry out activities that are necessary to run our facilities or programs, and to make sure that all our members receive quality care. For example, we may use medical information to review our services and to evaluate the performance of our staff in their care of and services to you. We may also combine medical information about our members in order to decide what additional services we should offer, what services may not be needed, and whether certain services or new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical or social work students or other MHA program personnel for review and learning purposes.

Appointment Reminders: We may use and disclose your PHI to contact you as a reminder that you have an appointment for services or treatment in our facility or program. For example, we may call your home and leave a message that identifies our agency and reminds you that you have an appointment with us.

Treatment Alternatives and Health-Related Products and Services: We may use and disclose your PHI to recommend possible treatment options or alternatives that may be of interest to you. We may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you (for example, Medi-Cal eligibility or Social Security benefits).

Individuals Involved in Your Care or Payment of Your Care: We may disclose your PHI to a friend or family member who is involved in your medical care or payment related to your care, provided you agree to this disclosure, or we give you an opportunity to object to this disclosure. However, if you are not available or are unable to agree or object, we will use our judgment to decide whether this disclosure is in your best interests.

Disaster Relief Purposes: We may disclose your PHI to an entity assisting in disaster or emergency relief efforts, so that your family can be notified about your condition, status and location. We will give you the opportunity to agree to this disclosure or object to this disclosure, unless we decide that we need to disclose your PHI in order to respond to the emergency circumstances.

Uses And Disclosures Of Your Medical Information
That Do Not Require Your Authorization

Research: We may disclose your PHI to medical researchers who request it for approved medical research projects; However, such disclosures must be cleared through a special approval process before any PHI is disclosed to the researchers who will be required to safeguard the PHI they receive.

As Required by Law: We will disclose your PHI when required to do so by federal, state or local law.

Worker’s Compensation: We may release your PHI for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose medical information about you for public health activities, such as those aimed at preventing or controlling disease, preventing injury or disability, and reporting the abuse or neglect of children, elders and dependent adults.

Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law. Examples of these oversight activities include audits, investigations, inspections and licensing. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include a written notice to you) or to obtain an order protecting the requested PHI.

Law Enforcement: We may disclose PHI to government law enforcement agencies in the following circumstances:

• In response to a court order, warrant, subpoena, summons or similar process issued by a court;

• If a psychotherapist believes that it is likely that you present a serious danger of violence to another person;

• If we believe you have committed or have been the victim of a crime, and you are currently hospitalized; disclosures must be limited to information that directly relates to the factual circumstances and must not include any information that relates to your mental health or the circumstances of your treatment;

• To report your discharge, if you were involuntarily detained after a peace officer initiated a 72-hour hold for evaluation and requested notification;

• In certain circumstances, if you have been admitted to a facility and have disappeared or been transferred.

Coroners, Medical Examiners and Funeral Directors: We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine a cause of death. We may also release medical information to funeral directors if it is necessary for them to have it to carry out their duties.

Specialized Government Functions: We may disclose your PHI to authorized federal officials for intelligence, counterintelligence or other national security activities as authorized by law. We may also disclose your PHI to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates: If you are an inmate or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care, (2) to protect your health and safety or the health and safety of others, or (3) for the safety and security of the correctional institution.

Other Uses of Your Medical Information

Other uses and disclosures of your PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your PHI you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by the authorization, except that we are unable to take back any disclosures we have already made when the authorization was in effect, and we are required to retain our records of the care and services that we provided you.

Your Rights Regarding Your PHI

You have the rights listed below regarding your PHI contained in our records.

Right to Inspect and Copy: With certain exceptions, you have the right to inspect and copy your PHI from our records. Usually, this includes treatment and billing records.

MHA has historically maintained and will continue to maintain a policy that permits members to review their charts at any mutually convenient time. MHA also has and will continue to maintain a policy permitting members to add their own notes to their charts. To review the PHI we maintain about you that may be used to make decisions about you, simply place an oral request with your PSC or the site director of your program. Arrangements will then be made to sit down with you to review your chart, and if you wish you may add your notes at that time.

If you request a copy of your PHI, you must do so in writing. We will provide you with a form entitled “Member Request for a Copy of Records” to make this request. We may charge you a fee for the costs of copying, mailing and other supplies associated with your request.

We may deny your request to inspect and copy your records in certain circumstances. If you are denied the right to inspect and copy your PHI in our records, you may request that the denial be reviewed. With the exception of a few circumstances that are not subject to review, a licensed healthcare professional within MHA, who was not involved in the denial, will review the decision. We will comply with the outcome of that review.

Right to Request an Amendment: As stated above, members may add their own personal notes to their chart at any time. However, if you feel that your PHI in our records is incomplete or incorrect and you want us to amend [delete or change] information in your chart, you must make this request in writing. You have the right to request amendments for as long as we keep your PHI.

To request an amendment, ask for a “Request to Amend Protected Health Information” form. Complete this form and give it to your PSC or the site director of your program.

We may deny your request for an amendment if it is not in writing or does not include a reason to support your request. In addition, we may deny your request if you ask us to amend PHI that:

• Was not created by us, unless you can provide us with a reasonable basis to believe that the person or entity who created the PHI is no longer available to make the amendment;

• Is not part of the PHI kept for or by MHA;

• Is not part of the PHI which you would be permitted to inspect and copy; or

• Is accurate and complete.

Even if we deny your request for amendment, you have the right to submit at Statement of Disagreement. This written Statement should not exceed 250 words, and should address the specific item or information in your record you believe is incorrect or incomplete. If you clearly indicate that you want the written Statement to be a part of your record, we will attach it to your record and include it whenever we make a disclosure of the item or record you believe to be incomplete or incorrect.

Right to Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of your PHI other than for our own uses for treatment, payment and healthcare operations [described earlier in this document] and with other exceptions allowed by law.

To request this list or “accounting of disclosures,” ask for a “Request for Accounting of Uses and Disclosures of Protected Health Information” form from your PSC or the site director of your program. Your request must state the time period [that may not be longer than six years] and may not include dates before April 14, 2003. The first list you request in any 12-month period is free. We may charge you fees for the cost of producing any additional list(s) you request within the same 12-month period. The fees are listed on the request form, and you may withdraw or modify your request before any costs are incurred.

Right to Request Confidential Communications: You have the right to request that we communicate with you about your health/mental health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must put your request in writing and give it to your PSC or the site director of your program. Your request must specify how and/or where you wish to be contacted. We will work to accommodate all reasonable requests.

Right to Request Restrictions: You may request that we follow additional, special restrictions when using or disclosing your PHI for treatment, payment or health care operations. You may also request that we follow additional, special restrictions when using or disclosing your PHI to someone who is involved in your care of the payment of your health care, like a family member or friend. For example, you could ask that we not use or disclose that you are receiving services at our facility. We are not required to agree with your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, ask for a “Opportunity for Member to Object to Uses and Disclosures of Protected Health Information for Three Special Purposes” form from your PSC or the site director of your program.

Right to a Paper Copy of This Notice: You have a right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have chosen to receive this Notice electronically [for example, by fax or by downloading it from our website], you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our website: http://www.mhala.org. To obtain a paper copy of this Notice, contact your PSC or the site director of your program.

Changes to This Notice

We reserve the right to change the terms of this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our program sites. The Notice will contain the effective date in the footnote section of document. If we change our Notice, you may obtain a copy of the revised Notice by visiting our website at http://www.mhala.org, or you may request one from your PSC or site director of your program.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Los Angeles County Department of Mental Health. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.

To file a complaint with us, or if you have questions or comments about our privacy practices, contact: Director of Administration, National Mental Health Association of Greater Los Angeles, 320 Pine Ave, Suite 610, Long Beach CA 90802. If you are not happy with the outcome of your complaint to us, you may file a complaint with DMH: Los Angeles County Department of Mental Health, Patient’s Rights Division, 550 South Vermont Avenue, Los Angeles, CA 90020, (213) 738-4949.