Privacy of Consumer Records – Consumer records and files shall be the property of UTAC (Utah Trauma & Addiction Centers) and shall be secure against loss, tampering, or unauthorized use. Confidentiality of consumer records will be ensured by restricting their availability only to those employees, agents or agencies of the program. UTAC cannot guarantee confidentiality once information leaves the Center.
I. Federal Confidentiality Laws
The program is restricted in its capability to disclose privileged and protected information. This privacy of information is for current and closed records as stated in the Code of Federal Regulations 42 CFR Part 2 and the federal Health Insurance Portability and Accountability Act (HIPPA). The UTAC makes every attempt to keep protected information from possible misuse. Written permission or a legal court order is required before release of records.
II. Client Confidentiality
Although unlikely, UTAC will notify the client, if for any reason, the security of PHI is breached. Staff are prohibited from disclosing the admission, presence, or any other protected information regarding a client in the program.
- Media Waiver – UTAC will not videotape or record a client without first obtaining the client’s written informed consent and approval from the owners of UTAC.
- Access to Consumer Records – The program shall maintain confidentiality for all clients’ case records. Employees of the program shall not discuss or knowingly permit the disclosures of any information concerning the client or his/her family, directly or indirectly, to any unauthorized person. The client and any persons that the client authorizes may have access to the consumer records; however, a signed release must be completed by the client and documented with the consumer file.
- Revocation of Consent – Anytime a client chooses to revoke consent, they should be encouraged to inform the entity being revoked by telephone or in writing that they are choosing to revoke the said consent. Revocation of consent may be grounds for ‘unsatisfactory discharge’ based on clinical decision.
- Right to Request Restrictions – The client has the right to request restrictions on certain uses and disclosures of protected health information. However, UTAC is not required to agree to a restriction.
- Right to Inspect and Copy – Clients have the right to inspect or obtain a copy of their mental health and billing records used to make decisions about them for as long as the PHI is maintained in the record. UTAC may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. Upon request, UTAC will discuss details of the request and denial process. There may be a fee for copying requested records.
- Right to Amend – Clients have the right to request an amendment of PHI as long as the PHI is maintained in the record. UTAC may deny this request. Upon request, UTAC will discuss with details of the amendment process.
- Right to an Accounting – Clients have the right to receive an accounting of disclosures of PHI for which they have neither provided consent nor authorization. Upon request, UTAC will discuss details of the accounting process.
- Right to a Paper Copy – Clients have the right to obtain a paper copy of notices even if they previously agreed to receive notices electronically.
- Right to Notice with Respect to PHI – UTAC is required by law to maintain the privacy of PHI and to provide clients with a notice of legal duties and privacy practices with respect to PHI.
- Protected Confidentiality – Is protected even if the request is made by someone who:
- Already has the information;
- Has other means of obtaining it;
- Has official status; and/or
- Is authorized by State law.
III. Exceptions to Client Confidentiality
- Signed consent form with proper format;
- Internal program communication;
- Client crimes on program premises;
- Research, audit, or evaluation;
- Qualified Service Organization Agreements (QSOA);
- Communications that safeguard client-identifying information;
- Serious Threat to Health or Safety – UTAC may disclose confidential mental health information to any person without authorization if the person disclosing information reasonably believes that disclosure will avoid or minimize imminent danger to health or safety of self, or the health or safety of another individual;
- Court-Ordered Disclosures – If a client is involved in a court proceeding and a request is made for information about professional services provided at the UTAC and/or the records thereof, such information is privileged under state law, and UTAC will not release information without the written authorization of the client or their legal representative, or a subpoena of which the client has been properly notified and failed to inform UTAC of opposition to the subpoena or court order. The privilege does not apply when the client is being evaluated for a third party or where the evaluation is court ordered. The client will be informed in advance if this is the case. UTAC will seek legal counsel to prevent the release of court-ordered records, but may still be required to release the records. Records that must be released may no longer be “confidential;”
- Lawsuits – Consumers should be aware that if they take legislative action against the UTAC, the owners, or clinicians for a personal injury, a portion of their record may become public information thus they may lose their right to confidentiality.
- Health Oversight – If the Utah State Department of Health subpoenas a member of UTAC treatment team as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed mental health professionals, UTAC must comply with its orders. This could include disclosing relevant mental health information;
- Worker’sCompensation – If a client files a worker’s compensation claim, with certain exceptions, UTAC must make available, at any stage of the proceedings, all mental health information in UTAC possession relevant to that particular injury in the opinion of the Utah Department of Labor and Industries, to an employer, representative, and the Department of Labor and Industries upon request;
- Abuse and Neglect Reporting
- Child Abuise – If staff has reasonable cause to believe that a child has suffered abuse or neglect, they are required by law to report it to the proper law enforcement agency or the Utah Department of Social and Health Services.
- Adult and Domestic Abuse – If staff have reasonable cause to believe that abandonment, abuse, financial exploitation, neglect, or sexual or physical assault of a vulnerable adult has occurred, they must immediately report the abuse to the proper law enforcement agency or the Utah Department of Social and Health Services.
IV. Privacy and Insurance Companies
Consumers that choose to use insurance as a means to cover treatment costs sign a release giving the insurance company rights to access their protected medical records. If the insurance company asks for more detailed information than usual, UTAC will attempt to consult with the consumer first. If the consumer opts not to provide their insurance carrier with information, they will be required to assume all financial responsibility for treatment costs not paid by their insurance;
- Disclosures for Treatment, Payment, and Health Care Operations – UTAC may use or disclose protected health information (PHI), for treatment, payment, and health care operations purposes with consent from the consumer. If UTAC is asked for information for purposes outside of treatment, payment, and health care operations, UTAC will obtain an authorization from the client before releasing this information. To help clarify these terms. The following are terms related to health care:
- “PHI” or Patient Health Information – refers to information in the consumer health record that could identify the client.
- “Treatment” – is when UTAC provides, coordinates, or manages health care and other services related to the client’s health care. An example of treatment would be when UTAC consults with another health care provider, such as a family physician or another mental health professional.
- “Payment” – is when UTAC obtains reimbursement for health care services. Examples of payment are when UTAC disclose PHI to a health insurer to obtain reimbursement for the client’s health care or to determine eligibility or coverage.
- “Health Care Operations” – are activities that relate to the performance and operation of the UTAC. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. “Use” applies only to activities within UTAC such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies a client.
- “Disclosure” – applies to activities outside of UTAC such as releasing, transferring, or providing access to information about a client to other parties.
- “Authorization” – is written permission above and beyond the general consent that permits only specific disclosures. Uses and Disclosures Requiring Authorization. UTAC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when appropriate authorization is obtained.
- “Psychotherapy notes” – are notes UTAC has made about conversation during a private, group, joint, or family counseling session. UTAC may keep these separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. Written authorization is required prior to releasing psychotherapy notes. The client may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing.
- The client may not revoke an authorization to the extent that (1) UTAC has previously acted in reliance on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
(PLEASE REVIEW CAREFULLY)
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your health record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your health record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 90 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us directly.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest.
We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Most sharing of psychotherapy notes
How do we typically use or share your health information? We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you or for medical emergencies.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Bill for services
We can use and share your health information to bill and get payment from health plans or other entities.
How else can we use or share your health information?
We are allowed or required to share your information in other ways; usually in ways that contribute to the public good, such as public health and research.
We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
In a medical emergency
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if they want to see that we’re complying with federal privacy law(s).
Conduct outreach, enrollment, care coordination, and case management
We can share health information about you with for reasons such as outreach, care coordination, and case management.
We can share health information to remind you of appointments
Work with a medical examiner
We can share health information with a medical examiner.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to an authorizing court order, or in response to a subpoena.
Comply with special laws
There are special laws the protect some types of health information such as mental health services, treatment for substance use disorders, and HIV/AIDS testing and treatment. We will obey these laws when they are stricter than this notice.
To auditors and evaluators
We can share health information about you to regulatory agencies, third-party payers, and peer review organizations that monitor alcohol and drug program regulatory compliance and accounting.
To report a crime on our premises or against our personnel
We can share health information about you to law enforcement about a crime committed on the premises or against our personnel
We do not sell your personal information.
We will never share any substance abuse treatment records without your written permission.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date: June 1, 2022