THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosure

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your mental health, diagnosing conditions, and providing treatment. For example, results of tests and procedures will be available in your clinical record to all behavioral health professionals who may provide treatment or who may be consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan or from other sources of coverage such as an automobile insurer. For example, your health plan may request and receive information on dates of service, the services provided, and the clinical condition being treated.

Health Care Operations. Your health information may be used as necessary to support the day-to-day activities and management of SpringHaven, Inc. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law Enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public Health Reporting. Your health information may be disclosed to public health agencies as required by law. For example, we may be required to report certain communicable diseases to the state's public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Additional Uses of Information

Appointment Reminders. Your health information will be used by our staff to send or call you appointment reminders. This may result in others in your household realizing that you have an appointment with our practice.

Information about Treatments. Your health information may be used to send you information on the treatment and management of your clinical condition that you may find to be of interest. We may also send you information describing other goods and service that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your clinical condition and treatment
• The right to inspect and copy your protected health information
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to contact the DHHS Secretary if you believe your privacy rights have been violated
• The right to receive a printed copy of this notice

SpringHaven, Inc.’s Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information

As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our Receptionist or Privacy Officer.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Office Manager
PO Box 265
Mt. Eaton, OH 44659

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint .

Contact Person

The name and address of the person you can contact for further information concerning our privacy practices is:

Jessica Miller – Office Manager
Phone: 330-359-6100 
PO Box 265
Mt. Eaton, OH 44659

If you are not satisfied with SpringHaven’s response to your Privacy Concerns, you may file a complaint with:

Region V Office for Civil Rights
US Dept. of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

Effective Date

This Notice is effective on or after April 14, 2003