HOW Seminole Behavioral Healthcare MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

For Treatment. Seminole Behavioral Healthcare may use your health information to provide you with clinical treatment or services. For example, information obtained by a doctor, ARNP, nurse, clinician, intern or other persons involved in taking care of you, will be recorded in your record. This information is necessary for these providers to determine what treatment you should receive.

For Payment. We may use and disclose clinical information about you so the treatment and services you receive at Seminole Behavioral Healthcare may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received at Seminole Behavioral Healthcare so your health plan will pay us or reimburse you for the treatment. 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. Seminole Behavioral Healthcare may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the clinical staff, or quality improvement personnel, and others to:

• Evaluate the performance of our staff;
• Assess the quality of care and outcomes in your case and similar cases;
• Learn how to improve our facilities and services; and
• Determine how to continually improve the quality and effectiveness of the behavioral health care we provide.

Appointment Reminders. We may use and disclose clinical information to contact you as a reminder that you have an appointment for treatment at Seminole Behavioral Healthcare.

Research/Program Evaluation. Under certain circumstances, we may use and disclose clinical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of clinical information, trying to balance the research needs with client's need for privacy of their clinical information. Before we use or disclose clinical information for research, the project will have been approved through this research approval process, but we may, however, disclose clinical information about you to people preparing to conduct a research project, for example to help them look for patients with specific clinical needs, so long as the clinical information they review does not leave Seminole Behavioral Healthcare. We will also always 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 Seminole Behavioral Healthcare.

As Required By Law. We may use and disclose information about you as required by law.

To Avert a Serious Threat to Health or Safety. We may use and disclose clinical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure however would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Workers' Compensation. We may release clinical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose clinical information about you for public health activities. These activities generally include the following:
• To prevent or control disease, injury or disability;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose clinical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, 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.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose clinical information about you in response to a court order.

Law Enforcement. We may release clinical information if asked to do so by a law enforcement official:
• In response to a court order;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at Seminole Behavioral Healthcare; and
• 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.

National Security and Intelligence Activities. We may release clinical information about you to authorized federal officials.

YOUR RIGHTS REGARDING CLINICAL INFORMATION ABOUT YOU.

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

Right to Inspect and Copy. You have the right to inspect and copy clinical information that may be used to make decisions about your care. Usually, this includes clinical and billing records.

To inspect and copy clinical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at Seminole Behavioral Healthcare. If you request a copy of the information, we may charge a reasonable 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 clinical information, you may request that the denial be reviewed. Another licensed professional selected by Seminole Behavioral Healthcare will review your request and the denial. The person conducting the 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 clinical 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 Seminole Behavioral Healthcare.

To request an amendment, please contact your clinician. If the clinician is no longer employed at Seminole Behavioral Healthcare, you may contact the supervisor.

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 clinical information kept by or for Seminole Behavioral Healthcare;
• 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 Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of clinical information about you.

To request this list of accounting of disclosures, you must submit your request in writing to the Privacy Officer at Seminole Behavioral Healthcare. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 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 cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the clinical information we use or disclose about you for treatment, payment or health care operations.

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 Privacy Officer at Seminole Behavioral Healthcare. 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.

Right to Request Confidential Communications. You have the right to request that we communicate with you about clinical 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 Privacy Officer at Seminole Behavioral Healthcare. 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. You have the right to 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 agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our web site, www.seminolecares.org

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for clinical 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 each Seminole Behavioral Healthcare location. The notice will contain on the first page the effective date. In addition, each time you register at or are admitted to Seminole Behavioral Healthcare for treatment, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Seminole Behavioral Healthcare or with the Secretary of the Department of Health and Human Services. To file a complaint with Seminole Behavioral Healthcare, contact the Privacy Officer at Seminole Behavioral Healthcare, 237 Fernwood Blvd., Fern Park, FL 32750. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF CLINICAL INFORMATION

Other uses and disclosures of clinical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose clinical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose clinical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Seminole Behavioral Healthcare will not redisclose any information contained in your clinical record that originated at another healthcare facility except with your written permission.

If you have any questions about this notice, please contact:

Privacy Officer
Seminole Behavioral Healthcare
237 Fernwood Blvd.
Fern Park, FL 32750
407-831-2411