Ora Clubhouse, Inc., has rights and responsibilities regarding the Protected Health Information of members. This Notice describes how health information about our members may be used and disclosed and how our members can get access to this information. This Notice applies to Ora Clubhouse, Inc. Please review it carefully.

 

You have the right to:

 

 

 

See pages 2 & 3 for more information on these rights and how to exercise them.

 

 

 

Your Rights

·    Get a copy of your paper or electronic medical record

·    Correct your paper or electronic medical record

·    Request confidential communication

·    Ask us to limit the information we share

·    Choose someone to act for you

·    Receive breach notifications

·    Get a list of those with whom we’ve shared your information

·    Get a copy of this Privacy Notice

·    File a complaint if you believe your Privacy Rights have been violated

 

 

You have some choice in the way that we use and share information as we:

 

See pages 3 & 4 for more information on these choices and how to exercise them.

 

 

Your Choices

·      Tell family and friends about your condition

·      Provide disaster relief

·      Include you in a directory (if applicable)

·      Provide behavioral health care

·      Market our service and sell your information

·      Raise Funds

 

 

 

 

 

 

 

 

Our Uses and

Disclosures

We may use and share your information as we:

·         Support and guide you

·         Run our organization

·         Bill for services

·         Work with our contracted Business Associates and subcontractors

·         Help with public health and/or public safety issues

·         Do research

·         Comply with the law

·         Respond to organ and tissue donation requests

·         Respond to lawsuits and legal actions

·         Work with a medical examiner or funeral director

·         Address workers’ compensation, health oversight agencies, law enforcement, and other government requests

·         Government agencies providing benefits or services

 

 

 

 

 

 

See pages 4 & 5 for more information on use & disclosure.

 

 

 

Your Rights

When it comes to your health information, you have certain rights.

 

 

 

 

 

Get an electronic or paper copy of your health record

·         You, or your designee, can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         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.

·         We are not required to allow you to see or copy psychotherapy notes, information prepared for use in legal actions or proceedings, or

where access is prohibited by law.

 

Ask us to correct mistakes in

your health records

·         You can ask us to correct health information about you that you think is incorrect or incomplete. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         We may say “no” to your request, but we will tell you why in writing within 60 days.

 

 

Request a specific method for confidential communications

·         You can ask us to contact you in a specific way (for example, you could request we contact you at your workplace or via email) or send mail to a different address. Your request must be in writing to our Clubhouse Director or authorized staff that maintains your records.

·         We may say “no” to your request, but we will tell you why in writing within 60 days.

 

 

 

 

Ask us to limit

what we use or share

·         You can ask us not to use or share certain health information. We are not required to agree to your request, and we may say “no” if it would affect your care.

·         You can ask us not to share certain health information with family members. We are not required to agree to your request, and we may say “no” if it would affect your care.

·         These requests must be in writing to the Clubhouse Director or authorized staff that maintains your records.

 

 

 

 

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. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         We confirm the person has this authority and can act for you before we take any action.

 

Receive breach

notifications

·         You will receive notification if there is a breach of your

unsecured protected health information (PHI).

 

 

 

 

Get a list of those with whom we’ve shared your protected health information

·         You can ask for a list (Accounting of Disclosures) 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. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         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).

 

 

Get a copy of this Notice

of Privacy Practices for Protected Health Information

·         You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. Please contact the Clubhouse Director or authorized staff and we will provide you with a paper copy promptly.

 

 

 

 

 

 

 

 

File a complaint if you feel your rights are violated

·         You can submit a complaint if you feel we have violated your rights by sending a letter to:

Ora Clubhouse, Inc.

P.O. Box 1268

Ocala, FL 34470 Clubhouse Director 352-402-9001

Or you can file a complaint with the

Florida Department of Children and Families, Office of Civil Rights, HIPAA Privacy Officer, 1317 Winewood Boulevard, Building 1, Room 110,

Tallahassee FL 32399-0700, Tel. 850-487-1901 Fax 850-921-8470

Or you can file a complaint with the

US Dept of Health and Human Services, Office for Civil Rights 200 Independence Avenue SW, Washington DC 20201

Or by calling 1-877-696-6775,

or at www.hhs.gov/ocr//privacy/hipaa/complaints/

·         We will not retaliate against you for filing a complaint.

 

 

Your Choices

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, please communicate to 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 move forward 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:

·         Marketing purposes.

·         Sale of your information.

·         Most sharing of psychotherapy notes.

 

In the case of fundraising:

·         We may contact you for fundraising efforts, but you can tell us not tocontact you again.

 

 

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways. Please note that not all types of uses and disclosures can be described or listed in this

Notice.

 

 

Member Support

·         We can use your health information and share it with other professionals who are treating you and coordinate services you may need.

Example: A doctor performing a clinical evaluation may talk another doctor about your overall

health condition.

 

 

Run our organization

·         We can use and share your health information to run our organization, improve your care,

and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

 

 

Bill for your services

·         We can use and share your health information to bill and get payment from health plans and other entities.

Example: We give information about you to your health insurance plan so it will

pay for your services.

 

 

Work with our contracted Business Associates and Subcontractors

·         Ora Clubhouse, Inc., contracts with the Department of Children and Families, other agencies, and businesses to carry out some of the services for which we are responsible. Examples would include case management agencies and behavioral treatment centers.

 

How else can we use or share your health information? We are allowed or required to share your information in the course of investigations, determining eligibility, providing care, services or other benefits, and 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:

·         Preventing disease

·         Helping with product recalls

·         Reporting adverse reactions to medications

·         Reporting suspected abuse, neglect, or domestic violence

·         Preventing or reducing a serious threat to anyone’s health or safety

Do research

·         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 it wantsto see that we are complying with federal privacy law.

 

Respond to organ and tissue

donation requests

·         We can share health information about you with organ

procurement organizations.

 

Respond to lawsuits and legal actions

·         We can share health information about you in response to a court or administrative order, or in response to a subpoena.

 

Work with a Medical Examiner or Funeral Director

·         We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

 

 

 

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, with a law enforcement official, orcorrectional institutions

·         With health oversight agencies for activities authorized by law

·         For special government functions such as military, national security, andpresidential protective services

 

Government agencies providing benefits or services

·        We can share your health information with other government agencies or programs that provide similar services or benefits to you if the release is necessary to coordinate the delivery of your services or benefits or improves our ability to administer or manage the program.

 

 

 

 

 

 

 

 

Acknowledgement of Receipt and Review of Notice of Privacy Practices and PHI

Member Number:                 

Instructions:

Please read this page closely, and ask any question you may have about this notice or Ora Clubhouse, Inc., then sign and date on the line at the bottom of this page.

We are required to confirm you  have been provided this notice and that you understand all of your rights and responsibilities prior to you and Ora Clubhouse, Inc., begin working together to achieve success and stability for you.

Acknowledgement:

I have received Ora Clubhouse, Inc., Notice of Privacy Practices. I had a chance to go over it with a representative from Ora Clubhouse, Inc., and have received answersto my questions. I understand how Ora Clubhouse, Inc., will be working to help me, how to make a complaint, and how my complaint will be handled.

Member Signature:

 

 

Signature

 

Print Name

 

Date

 

Ora Clubhouse, Inc., Staff Signature:

 

Signature

 

Print Name

 

Date

 

Ora Clubhouse, Inc., has rights and responsibilities regarding the Protected Health Information of members. This Notice describes how health information about our members may be used and disclosed and how our members can get access to this information. This Notice applies to Ora Clubhouse, Inc. Please review it carefully.

 

You have the right to:

 

 

 

See pages 2 & 3 for more information on these rights and how to exercise them.

 

 

 

Your Rights

·    Get a copy of your paper or electronic medical record

·    Correct your paper or electronic medical record

·    Request confidential communication

·    Ask us to limit the information we share

·    Choose someone to act for you

·    Receive breach notifications

·    Get a list of those with whom we’ve shared your information

·    Get a copy of this Privacy Notice

·    File a complaint if you believe your Privacy Rights have been violated

 

 

You have some choice in the way that we use and share information as we:

 

See pages 3 & 4 for more information on these choices and how to exercise them.

 

 

Your Choices

·      Tell family and friends about your condition

·      Provide disaster relief

·      Include you in a directory (if applicable)

·      Provide behavioral health care

·      Market our service and sell your information

·      Raise Funds

 

 

 

 

 

 

 

 

Our Uses and

Disclosures

We may use and share your information as we:

·         Support and guide you

·         Run our organization

·         Bill for services

·         Work with our contracted Business Associates and subcontractors

·         Help with public health and/or public safety issues

·         Do research

·         Comply with the law

·         Respond to organ and tissue donation requests

·         Respond to lawsuits and legal actions

·         Work with a medical examiner or funeral director

·         Address workers’ compensation, health oversight agencies, law enforcement, and other government requests

·         Government agencies providing benefits or services

 

 

 

 

 

 

See pages 4 & 5 for more information on use & disclosure.

 

 

 

Your Rights

When it comes to your health information, you have certain rights.

 

 

 

 

 

Get an electronic or paper copy of your health record

·         You, or your designee, can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         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.

·         We are not required to allow you to see or copy psychotherapy notes, information prepared for use in legal actions or proceedings, or

where access is prohibited by law.

 

Ask us to correct mistakes in

your health records

·         You can ask us to correct health information about you that you think is incorrect or incomplete. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         We may say “no” to your request, but we will tell you why in writing within 60 days.

 

 

Request a specific method for confidential communications

·         You can ask us to contact you in a specific way (for example, you could request we contact you at your workplace or via email) or send mail to a different address. Your request must be in writing to our Clubhouse Director or authorized staff that maintains your records.

·         We may say “no” to your request, but we will tell you why in writing within 60 days.

 

 

 

 

Ask us to limit

what we use or share

·         You can ask us not to use or share certain health information. We are not required to agree to your request, and we may say “no” if it would affect your care.

·         You can ask us not to share certain health information with family members. We are not required to agree to your request, and we may say “no” if it would affect your care.

·         These requests must be in writing to the Clubhouse Director or authorized staff that maintains your records.

 

 

 

 

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. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         We confirm the person has this authority and can act for you before we take any action.

 

Receive breach

notifications

·         You will receive notification if there is a breach of your

unsecured protected health information (PHI).

 

 

 

 

Get a list of those with whom we’ve shared your protected health information

·         You can ask for a list (Accounting of Disclosures) 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. Your request must be in writing to the Clubhouse Director or authorized staff that maintains your records.

·         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).

 

 

Get a copy of this Notice

of Privacy Practices for Protected Health Information

·         You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. Please contact the Clubhouse Director or authorized staff and we will provide you with a paper copy promptly.

 

 

 

 

 

 

 

 

File a complaint if you feel your rights are violated

·         You can submit a complaint if you feel we have violated your rights by sending a letter to:

Ora Clubhouse, Inc.

P.O. Box 1268

Ocala, FL 34470 Clubhouse Director 352-402-9001

Or you can file a complaint with the

Florida Department of Children and Families, Office of Civil Rights, HIPAA Privacy Officer, 1317 Winewood Boulevard, Building 1, Room 110,

Tallahassee FL 32399-0700, Tel. 850-487-1901 Fax 850-921-8470

Or you can file a complaint with the

US Dept of Health and Human Services, Office for Civil Rights 200 Independence Avenue SW, Washington DC 20201

Or by calling 1-877-696-6775,

or at www.hhs.gov/ocr//privacy/hipaa/complaints/

·         We will not retaliate against you for filing a complaint.

 

 

Your Choices

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, please communicate to 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 move forward 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:

·         Marketing purposes.

·         Sale of your information.

·         Most sharing of psychotherapy notes.

 

In the case of fundraising:

·         We may contact you for fundraising efforts, but you can tell us not tocontact you again.

 

 

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways. Please note that not all types of uses and disclosures can be described or listed in this

Notice.

 

 

Member Support

·         We can use your health information and share it with other professionals who are treating you and coordinate services you may need.

Example: A doctor performing a clinical evaluation may talk another doctor about your overall

health condition.

 

 

Run our organization

·         We can use and share your health information to run our organization, improve your care,

and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

 

 

Bill for your services

·         We can use and share your health information to bill and get payment from health plans and other entities.

Example: We give information about you to your health insurance plan so it will

pay for your services.

 

 

Work with our contracted Business Associates and Subcontractors

·         Ora Clubhouse, Inc., contracts with the Department of Children and Families, other agencies, and businesses to carry out some of the services for which we are responsible. Examples would include case management agencies and behavioral treatment centers.

 

How else can we use or share your health information? We are allowed or required to share your information in the course of investigations, determining eligibility, providing care, services or other benefits, and 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:

·         Preventing disease

·         Helping with product recalls

·         Reporting adverse reactions to medications

·         Reporting suspected abuse, neglect, or domestic violence

·         Preventing or reducing a serious threat to anyone’s health or safety

Do research

·         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 it wantsto see that we are complying with federal privacy law.

 

Respond to organ and tissue

donation requests

·         We can share health information about you with organ

procurement organizations.

 

Respond to lawsuits and legal actions

·         We can share health information about you in response to a court or administrative order, or in response to a subpoena.

 

Work with a Medical Examiner or Funeral Director

·         We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

 

 

 

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, with a law enforcement official, orcorrectional institutions

·         With health oversight agencies for activities authorized by law

·         For special government functions such as military, national security, andpresidential protective services

 

Government agencies providing benefits or services

·        We can share your health information with other government agencies or programs that provide similar services or benefits to you if the release is necessary to coordinate the delivery of your services or benefits or improves our ability to administer or manage the program.

 

 

 

 

 

 

 

 

Acknowledgement of Receipt and Review of Notice of Privacy Practices and PHI

Member Number:                 

Instructions:

Please read this page closely, and ask any question you may have about this notice or Ora Clubhouse, Inc., then sign and date on the line at the bottom of this page.

We are required to confirm you  have been provided this notice and that you understand all of your rights and responsibilities prior to you and Ora Clubhouse, Inc., begin working together to achieve success and stability for you.

Acknowledgement:

I have received Ora Clubhouse, Inc., Notice of Privacy Practices. I had a chance to go over it with a representative from Ora Clubhouse, Inc., and have received answersto my questions. I understand how Ora Clubhouse, Inc., will be working to help me, how to make a complaint, and how my complaint will be handled.

Member Signature:

 

 

Signature

 

Print Name

 

Date

 

Ora Clubhouse, Inc., Staff Signature:

 

Signature

 

Print Name

 

Date