Privacy

At Smack Foundation, Inc., we respect your right to privacy. We will never sell or rent your name, e-mail address, physical address and any other identifying information that you give us with any third party. By signing up for our program and becoming a registered subscription member to our Newsletter or by submitting our on-line consultation form, you agree to receive occasional e-mails from our Foundation which will not be considered Spam or Abuse.

Your Privacy, Your Rights Smack Foundation, Inc.  wants you to know How we keep your medical information private Your Rights as a health/ mental health care client How you can access this information Smack Foundation, Inc.  NOTICE OF Privacy Policies Please Review Carefully We are required by law to protect Medical Information about you. Like What? Information about Health or Mental Health care services that we provide for you. Information about you payment for those services. Information about your past, present and future health or mental health care conditions. Are You Aware… That a medical record chart is kept on every client. That every time Smack Foundation, Inc.  sees you, talks to you, or anyone else about your situation, a written note is put in your medical record chart. Other items that are kept in your medical record may include: A referral/identification sheet Mental Health service admission information Diagnosis Your signed service plan Release of information forms signed by you A consent for treatment signed by you Psychological and/or physical test results Other information that may help plan for your future treatment. The written notes in your record are proof that services were provided to you. Smack Foundation, Inc.  bills insurance companies or Medicaid for services provided. Co-pays will be collected at each appointment (if applicable). All fees are disclosed and agreed upon before treatment is rendered. You may review or obtain a copy of documents in your medical record written by Smack Foundation, Inc.  Staff by making a written request to your therapist /provider. All requests are honored within 14 days of its receipt. Smack Foundation, Inc.  DOES NOT engage in search and seizure procedures of any kind. I understand that unless other agreements have been made between me and my therapist, Smack Foundation, Inc.  Associates have the right to either suspend or terminate my treatment if I miss three (3) sessions within a six (6) week period. Upon termination, therapist/staff will make a referral to comparable services and complete a discharge plan (if applicable). If you understand what is in your Medical Record and why it is there, you can make informed decisions about who needs to know your business, and what needs to be disclosed to others. When Can We Give Your Information to Others? When: Your health/mental health information may be needed by a therapist, doctor, case manager, psychiatrist or other members of your health care team.This can help provide you with the best treatment if everyone necessary has the same information, goals, and future plans. Your health/ mental health care information may be needed by Smack Foundation, Inc.  for payment and billing purposes. The bill may include identifying information about your diagnoses, your Smack Foundation, Inc.  service staff, and the services you are receiving. Your health/mental health care information may be used by Smack Foundation, Inc.  staff to evaluate the quality of our program. Internal audit and reviews are conducted because we want to constantly improve the way we do our business. Your medical records may be reviewed to ensure quality assurance and promote best practices. Your health/ mental health care information may be released to a relative, friend, or other person to whom you give written permission to view. If you are minor, Smack Foundation, Inc.  may give your health/mental health care information to parent, legal guardian, or other legally responsible adult except when: You are receiving substance abuse treatment o You are pregnant and want services o If you are minor, you must sign a release of information allowing Smack Foundation, Inc.  to disclose substance abuse or pregnancy information. o If you sign a release of information, we will disclose your health/mental health information to identified parties. Smack Foundation, Inc.  may use or disclose certain protected health information without your written authorization in the following circumstances: When there is immediate danger to the health or safety to you or another individual. When public health safety requires an investigation by a government agency about communicable disease, adult or child abuse and neglect, or domestic violence. When the state or the federal government is investigating possible Medicaid/ Medicare fraud. When the federal government needs information about you for national security and intelligence services. Please Note: This is not complete list. Except for the above you are the only one who can authorize the release of the information about you. Smack Foundation, Inc.  has a separate “Authorization for Disclosure” form that must be signed by you for every agency, organization, individuals or facility that requires your health/ mental health care information. This form also states the specific information Smack Foundation, Inc.  can release. This form is valid for only one year. You may change your mind at anytime and revoke your authorization. You MAY NOT revoke billing information for services already performed. We will revoke your authorization upon request except when we have already made contact with your approval. If you revoke the release of information form- Smack Foundation, Inc.  will write “void” across the front and date it. You can revoke a “Release” in writing, over the phone or by contacting the Smack Foundation, Inc.  Privacy officer. What If you are being Seen for Substance Abuse Problems? Federal law restricts the use and disclosure of patient information that is received by an alcohol or drug abuse treatment program. Generally, substance abuse information must not be disclosed without your written authorization. For example, we would need your written authorization before we could disclose substance abuse information to your insurance provider for the purpose of obtaining reimbursement for the cost of services provided to you. The federal law protecting substance abuse treatment information applies only to information that would identify a substance abuse patient, directly or indirectly as an alcohol abuser or a recipient of alcohol or drug services. In addition to restricting disclosure, the federal law places restrictions on the use of information to initiate or substantiate any criminal charges against a patient or to conduct a criminal investigation of a patient. As stated above, federal law generally requires that we obtain your written consent before we may disclose information that would identify you as a substance abuser or a patient of substance abuse services. However, there are some important exceptions to this requirement. • We can disclose information within our program to members of our workforce as needed to coordinate your care. For example, information obtained about you by a therapist, psychiatrist, nurse, or other member of our healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. • We may also disclose your information to agencies that help us carry out our responsibilities in serving you with whom we have a Business Associate Agreement. • We may disclose your information within our program to carry out our healthcare operations. For example, members of the treatment team and quality improvement staff may use information in your record to assess the care and outcomes in your case. • We may disclose information to medical personnel in a medical emergency. If we suspect that a child is abused or neglected, state law requires us to report the abuse or neglect to the Department of Social Services, and we may disclose substance abuse treatment information when making the report. • We will disclose information about you if a court orders us to do so. If you commit a crime, or threaten to commit a crime, on the premises of our program or against our program personnel, we may disclose information about you or talk to law enforcement officers about the crime or threat. • We also may disclose information for research, audit or evaluations. What are your Health Care Information Rights? You have the right to request restrictions on certain uses and disclosures of protected health information. You may make requests in writing by filling out a Restriction Request form obtained from any of our sites. We will consider your request however; we are not required to agree to a requested restriction. You have the right to request confidential communications of protected health information be made using alternative means. For example, you have the right to ask us to send your healthcare information to or contact you at an address or phone number that is different than your home. We will agree to your request as long as it is reasonably easy for us to do so. You must make this request in writing by filling out an Alternative Method of Contact form (Appendix C-4), which you may obtain from any of our sites. Please be aware that cell phones may not be a secure means of communicating. You have the right to a paper copy of these privacy practices. We will give you another copy anytime you ask. A copy of these Privacy Practices is posted in our offices. In most cases, you have the right to look at or get a copy of your records by making written request to the Privacy Officer. You may obtain an Access Request form. Upon receiving your request, we will process it within 30 days. If you would like a copy of your health/mental health care information we may charge for the time and materials it takes to copy it. If we deny your request, we will explain ourselves in writing. You may appeal our denial to the Executive Director of Smack Foundation, Inc. , Dr. Lauren Durant. If you believe that your health information is wrong or some information is missing in your record, you must request, in writing, that we correct or add to the record by writing a letter to the Privacy Officer. We will respond within 60 days of receiving your request. We may deny the request if we determine that the information is: (1) correct & complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed, i.e. information compiled in anticipation of a civil proceeding. Any denial will state the reason for denial and explain your rights to have the request and denial, along with any statement in response that you provide, added to your health information. If we approve the request for amendment, we will change the information in your record, inform you, and tell others who need to know about the change. You have the right to request an accounting (which is a detailed list) of disclosures we have made while providing services for you. If you would like to receive an accounting, you may send a letter requesting an accounting to the Privacy Officer. We must act on this request no later than 60 days after receipt of the request. Please note that the accounting does not include disclosures made for treatment, payment or health care operations. If you request an accounting more than once every 12 months, we may charge you a fee to cover the costs of preparation. YOUR CLIENT RIGHTS Did You Know? As a client, you have certain rights. These rights are based on Smack Foundation, Inc.  Service’s policies as well as Article 3 of the North Carolina Mental Health Statues. Article 3 defines a client’s rights in receiving mental health, developmental disabilities, or substance abuse services. We Promise: To honor you privacy. To treat you with dignity and respect. To help you make informed choices. To inform you of how to get help in an emergency. To develop an individualized service plan and include you in the process. That you can see your service plan or any other information that Smack Foundation, Inc.  has written regarding you any time you request. To treat you and your family humanely and kindly. Our staff will not abuse/neglect or exploit you mentally or physically. To keep you informed of any potential risks of the services when appropriate. That you have the right to refuse any services offered. Not to sell any goods to you or buy any goods from you. To be free from search and seizure. To receive services without risk of suspension or expulsion What we do: All Smack Foundation, Inc.  staff must sign a confidential agreement which states that the employee cannot share any information about you or your family without your written permission except: When you sign a release form; When we believe that you or a family member might harm yourself or someone else, or that you have committed a crime; In an emergency medical situation; or when a judge issues a court order directing the release of you records. If we come to your home and we suspect child abuse or neglect, we are required by law to make a report to The Department of Social Services. In order to provide you with the best care, Smack Foundation, Inc.  staff may need to share information on your case with other Smack Foundation, Inc.  supervisors or representative for the local mental health center that referred you. What Can You Do? You can contact the Governor’s Advocacy Council for Person’s with Disabilities (GACPD), the statewide agency designated under Federal and State law to protect and advocate the rights of persons with disabilities. The number of the GACPD is 1-800-821-6922. • If you do not like our services you have the right to file a grievance or a complaint. Please contact Smack Foundation, Inc.  Executive director at (919) 489-3200. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that we provide and explain our legal duties and privacy practices with respect to health and mental health care information. We are legally bound to follow the terms of HIPAA as described in this brochure. We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new Notice effective for all health care information that we maintain. If we make changes to the Notice, we will: • Post the new Notice in our waiting area • Have copies of the new Notice available upon request. YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES. If you have questions, think we have violated your privacy rights, or want to complain to us about our privacy practices, you can contact Smack Foundation, Inc. , Inc.’s President: Patrick Walters . You may also send a written complaint to the Department of Health and Human Services at: Office for Civil Rights Department of Health & Human Services 61 Forsyth Street, SW. - Suite 3B70 Atlanta, GA 30323 (404) 562-7886; (404) 331-2867 (TDD) (404) 562-7881 Fax. If you file a complaint, we will not take any action against you or change our treatment of you in any way. When you have had these rights explained and have received a copy, please sign the Client Rights Signature form to acknowledge receipt of this Notice of Privacy Practices. Effective Date of this notice – January 7, 2000.

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