For Payment -- We may use and disclose behavioral healthcare information about you, with written authorization, so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, the King County RSN, or a third party, including Medicaid and Medicare. For example, we may need to give your health plan information about psychiatric care and treatments you received so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations -- We may use and disclose behavioral healthcare information about you for agency operations. These uses and disclosures are necessary to run the behavioral healthcare agency and make sure that all of our consumers receive quality care. For example, we may use behavioral healthcare information to review our treatment and services, and to evaluate the performance of our staff in caring for you. We, or our designee, may send you a consumer satisfaction survey. We may also combine behavioral healthcare information about many agency consumers to decide what additional services the agency should offer, what services are not needed and whether certain new treatments are needed or are effective. We may also disclose information to clinicians, doctors, case managers or other behavioral healthcare personnel for review and learning purposes. We may also combine the behavioral healthcare information from other agencies to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of behavioral healthcare information so others may use it to study behavioral healthcare and behavioral healthcare delivery without learning who the specific patients are. We may share information with the Mental Health Division when they inspect the quality of our operation for licensure purposes.

Substance Abuse Health Information. The confidentiality of alcohol and drug abuse consumer records related to the diagnosis, treatment, referral for treatment or prevention, is protected by federal law and regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3) and regulation (42 C.F.R. part 2). Generally, a substance abuse program may not disclose to anyone outside the program that a member attends the program or disclose any information identifying a member as an alcohol or drug abuser, unless:

• The member consents in writing, or
• The disclosure is allowed by a court order, or
• The disclosure is made to medical personnel in a medical emergency or to a qualified personnel for research audit or program evaluation, or
• The member commits or threatens to commit a crime either at the program or against any person who works for the program.
• Violations of the federal law and regulations by a program are a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs, or to the Valley Cities Counseling & Consultation’s Privacy Officer. Federal law and regulations do not protect any information about suspected child or adult/older adult abuse and neglect from being reported under state law to appropriate state or local authorities.

HIV Information. All health information regarding HIV is kept strictly confidential and released only in conformance with the requirements of state law. Disclosure of any medical information referencing a member’s HIV status may only be made with the specific written authorization of the member. A general authorization for the release of medical or other information is not sufficient for this purpose.

SPECIAL CIRCUMSTANCES

Federal and state laws allow or require us to disclose health information about you in certain special circumstances that include, but are not limited to, the situations described below:

1. Appointment Reminders -- To contact you as a reminder that you have an appointment for treatment or medical care at the agency.

2. Treatment Alternatives -- To tell you about or recommend possible treatment options or alternatives that may be of interest to you.

3. Health-Related Benefits and Services -- To tell you about health-related benefits, services, or medical or mental health education classes that may be of interest to you.

4. Fundraising Activities -- To contact you in an effort to raise money for the agency and its operations. This information will not be released outside Valley Cities Counseling & Consultation. If you do not want the agency to contact you for fundraising efforts, you must notify our Privacy Officer in writing. You may call 253 (833-7444 x 3501) to request further information.

5. Individuals Involved in Disaster Relief -- In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

6. Individuals Involved in Your Care or Payment for Your Care -- To a family member only with your written consent. We may also give information to someone who helps pay for your care only with your written authorization.

7. Research – Overall, Valley Cities Counseling & Consultation does not conduct research studies. Occasionally, however, we may be asked to participate in studies undertaken by the state or a university. In those rare cases, any information shared would be de-identified or we will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the agency.

8. As Required by Law -- When required by to do so by federal, state or local law.

9. Organ and Tissue Donation -- If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation or transplant.

10. Military -- If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

11. Workers Compensation -- To workers compensation or similar programs. These programs provide benefits for work-related injuries or illness.

12. Public Health Risks (Health and Safety to you and/or others) -- For public health activities. We may use and disclose medical information about you to agencies when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:

a. To prevent or control disease, injury or disability;
b. To report births or deaths;
c. To report child, adult, or older adult abuse or neglect;
d. To report reactions to medications or problem with prescriptions;
e. To notify a person who may have been exposed to a disease or at risk for contracting or spreading a disease or condition;
f. To notify the appropriate government authority if we believe a person has been the victim of abuse or domestic violence. We will only make this disclosure when required or authorized by law; and
g. To avert a serious threat to the health or safety of a person or the public.

13. Health Oversight Activities -- To a health oversight agency for activities authorized by law. These oversight activities include, for example, RSN, state, inter-agency audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

14. Lawsuits and Disputes -- If you are involved in a lawsuit or a dispute, we may disclose behavioral healthcare information about you in response to a court or administrative order. We may also disclose behavioral healthcare information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

15. Law Enforcement -- If asked to do so by a law enforcement official or:

a. In response to a court order, subpoena, warrant, summons or similar process;
b. To identify or locate a suspect, fugitive, material witness or missing person;
c. About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
d. About a death we believe may be the result of criminal conduct;
e. In emergency circumstances to report a crime; the location of the crime or victims; or the identity description or location of the person who committed the crime.

16. Coroners, Medical Examiners and Funeral Directors -- To a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death, and to funeral directors as necessary to carry out their duties.

17. National Security and Intelligence Activities -- To authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

18. Protective Services for the President and Others -- To authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special.

19. Inmates -- If you are an inmate of a correctional institute or under the custody of law enforcement official, we may release medical information about you to the correctional institute or law enforcement official. This release may be necessary (1) for the institute to provide you with health care; (2) to protect the health and safety of others; or (3) for the safety and security of the correctional institute.


YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy— You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit a written request to the Medical Records Department. Staff can assist you with submitting the request, if necessary. If you request a copy of the information, we will charge you a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by VCCC will review your request and the denial. The person conducting your review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend— If you feel that the medical information we have about you is incorrect or incomplete you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for VCCC.

A client who disagrees with any entry may make a separate entry, which shall be signed and dated by the individual and entered in the medical record. To request an amendment, your request must be made in writing and submitted to the Medical Records Manager. In addition, you must provide a reason that supports your request.

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

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the medical information kept by or for VCCC;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.

Right to an Accounting of Disclosure— You may have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you to others except for those under an authorization (if modifications are finalized) or for purpose of treatment, payment and operations identified above.

To request this list or accounting of disclosures, you must submit your request in writing to the Medical Records Manager. Your request must state a time period, which may not be longer than six years and may not include dates before April 2003. Your request should indicate in what form you want this list (for example: on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs of providing the list and give you an opportunity to withdraw or modify your request before any costs are incurred.

Right to Request Restrictions— You have the right to request a restriction on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a medication you were taking.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Medical Records Manager. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use,
disclosure or both; and (3) to whom you want the limits to apply, for example, disclosure to your spouse.

Right to Request Confidential Communications— You have the right to request that we communicate with you about medical 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 make your request in writing to the Medical Records Manager. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice— If you received this notice over the internet or via email, you have the right to a paper copy of this privacy notice. You may ask us to give you a copy of this privacy notice at any time by requesting a copy from any staff member.

CHANGES TO THIS NOTICE
Valley Cities Counseling & Consultation reserves the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information VCCC already has about you as well as any information we will receive in the future. We will post a copy of the current notice at all of our service sites and on our website. The notice will contain the effective date at the bottom of each page. VCCC will make you aware of any revisions by posting a revised notice in all the above locations.

COMPLAINTS
If you believe your privacy rights have been violated, you may contact or file a complaint in writing to the VCCC Privacy Officer by filling out a complaint form or sending a complaint to 2704 I St NE, Auburn, WA 98002. For further questions, you may contact the VCCC Privacy Officer at (253) 833-7444 x 3501. If we cannot resolve your concern, you also have the right to file a written complaint with the United States Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

OTHER USES
Other uses and disclosures of medical information not covered by this notice or the laws that apply to Valley Cities Counseling & Consultation will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, VCCC will no longer use or disclose medical information about you for the reasons covered in your written authorization. You understand that we are unable to take back any disclosures already made with your permission, and that we are required to retain our records of the care and services we provided to you.