Notice of Privacy Practices

What is my Protected Health Information?

• Anything from the past, present or future;
• About your mental or physical health or condition;
• That is spoken, written, or electronically recorded, and is;
• Created or maintained by us as your health care provider.

What Rights Do I Have About My Protected Health Information?

1. You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. The Free Clinic is not required to agree to the restriction that you requested.
2. You have the right to see and copy your Protected Health Information. 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.Exceptions to this include copies of psychotherapy notes.
3. You have the right to request that we amend your Protected Health Information. This request must be made in writing, but we can assist you with that.
4. You have a right to a paper copy of this Notice of Privacy Practices. We may change the terms of this Privacy Notice from time to time. You can always get a copy of the current Privacy Notice by requesting it from the front desk.
5. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Privacy Officer.

How will The Free Clinic use and disclose my Protected Health Information?

The Free Clinic collects Protected Health Information from you and stores it in a chart or on a computer. The client record is the property of The Free Clinic, but the information in the record belongs to you. The Free Clinic protects the privacy of your Protected Health Information. You do not need to sign an authorization form (a release) in order for us to use or disclose your health information for these purposes.

• Treatment: We can share information about your health with other specialists in our agency so that you receive the most appropriate treatment.
• Payment: We can share information about when and for what purpose you were seen, so that we can be paid for treating you. For example, we could send information to funding agencies and payors stating when and for what condition you were at the office. They can then send us money to help cover your costs of being seen.
• Health Care Operations: During the course of providing this treatment, there may be times when supervisors, and quality assurance staff of The Free Clinic see the records of the client. The purpose of these reviews are to ensure the quality of the services, the need for the continuation or the modification of the treatment plan, and to ensure that the record keeping and content is in compliance with regulatory body requirements. Supervisors or staff from Quality Assurance will review records using a "compliance checklist." The checklist includes required documentation such as a signed clients rights and responsibility form and signed client grievance.
• We will also share health information about you if it is needed in an emergency treatment situation. For example, we may provide your health information to a paramedic who is transporting you in an ambulance.
• We may contact you by phone or mail to provide appointment reminders.
• We may contact you regarding treatment alternatives or other health related benefits.
• In the event The Free Clinic is sold or merged with another organization, your Protected Health Information/record will become the property of the new owner.

• There are some circumstances in which we are required by law to share health information about you:
• For public health activities
• To protect victims of abuse or neglect
• To avert serious threats to health or safety
• Threat to self or others
• When subpoenaed by law we may disclose:
• For judicial and administrative proceedings
• For law enforcement purposes

What can be done with my information if I authorize its disclosure for other purposes?

There are times when there is a need for information to be shared with other community providers to better understand how to proceed with treatment. For example, if a client needs an outside psychiatric consultation, a referral for this service will be made. In these instances the client will be asked to sign an authorization for disclosure of information. The specific kind of information to be shared, and the date of this disclosure, including expiration date will be included in the disclosure form.

Can I cancel my authorization?

Yes. You can cancel your authorization. You must do this in writing and we will stop sharing your Protected Health Information. We are permitted to share your Protected Health Information based on your authorization until we receive your revocation in writing. You should understand that we are unable to take back any disclosures we have already made with your permission. Also, we are required to retain our records of the care that we provided to you.

What will you do to protect my health information?

We will maintain the privacy of your Protected Health Information as required by law. At your request, we will provide you with a Privacy Notice containing our legal responsibilities and privacy practices regarding Protected Health Information.

We reserve the right to change the terms contained in this Privacy Notice. If we do this, it will affect all Protected Health Information maintained by us. We will notify you that we have changed the Privacy Notice by posting it at our offices. You may obtain a copy from the front desk or by contacting the Privacy Officer (see the contact information below).

What can I do if I have questions or want to complain about the use and disclosure of my Protected Health Information?

All questions and complaints about the use and disclosure of your Protected Health Information may be sent to:

Privacy Officer
12201 Euclid Avenue
Cleveland, Ohio     44106

(216) 721-4010