Notice Of Privacy Practices

I. 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

II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION
(PHI)
We are legally required to protect the privacy of your PHI, which includes information that can be
used to identify you that we’ve created or received about your past, present, or future health or
condition, the provision of health care to you, or the payment of this health care. We must provide
you with this Notice about our privacy practices, and such Notice must explain how, when, and why
we will “use” and “disclose” your PHI. A “use” of PHI occurs when we share,

examine, utilize, apply, or analyze such information within our practice; PHI is “disclosed” when it is
released, transferred, has been given to, or is otherwise divulged to a third party outside of our
practice. With some exceptions, we may not use or disclose any more of your PHI than is necessary
to accomplish the purpose for which the use or disclosure is made. And, we are legally required to
follow the privacy practices described in this Notice.
However, we reserve the right to change the terms of this Notice and our privacy policies at any
time. Any changes will apply to PHI on file with us already. Before we make any important changes
to our policies, we will promptly change this Notice and post a new copy of it in our facility. You can
also request a copy of this Notice from us in person.

III. HOW WE MAY USE AND DISCLOSE YOUR PHI.

We will use and disclose your PHI for many different reasons. For some of these uses or
disclosures, we will need your prior written authorization; for others, however, we do not. Listed
below are the different categories of our uses and disclosures along with some examples of each
category.
A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not
Require Your Prior Written We can use and disclose your PHI without your consent for the following
reasons:

1. For Treatment, we can use your PHI within Warner Park Recovery Center to provide you
with mental health treatment, including discussing or sharing your PHI with all Warner Park
Recovery Center We can disclose your PHI to physicians, psychiatrists, psychologists, and
other licensed health care providers who provide you with health care services or are
involved in your care. For example, if a psychiatrist is treating you, we can disclose your PHI
to your psychiatrist to coordinate your care.
2. To Obtain Payment for We can use and disclose your PHI to bill and collect payment for the
treatment and services provided by us to you. For example, we might send your PHI to your
insurance company or health plan to get paid for the health care services that we have
provided to you. We may also provide your PHI to our business associates, such as billing
companies, claims processing companies, and others that process our health care claims.
3. For Health Care We can use and disclose your PHI to operate Warner Park Recovery
Center. For example, we might use your PHI to evaluate the quality of health care services
that you received or to evaluate the performance of the health care professionals who
provided such services to you. We may also provide your PHI to our accountant, attorney,
consultants, or others to further the health care operations.
4. Client Incapacitation or We may also disclose your PHI to others without your consent if you
are incapacitated or if an emergency exists. For example, your consent isn’t required if you
need emergency treatment, as long as we try to get your consent after treatment is rendered,
or if we try to get your consent but
B. you are unable to communicate with us (for example, if you are unconscious or in severe pain)
and we think that you would consent to such treatment if you were able to do so.
1. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Warner Park
Recovery Center can use and disclose your PHI without your consent or authorization for
the following reasons:
2. When federal, state, or local laws require For example, we may have to make a disclosure to
applicable governmental officials when a law requires us to report information to government
agencies and law enforcement
3. When judicial or administrative proceedings require For example, if you are involved in a
lawsuit or a claim for workers’ compensation benefits, we may have to use or disclose your
PHI in response to a court or administrative order. We may also have to use or disclose your
PHI in response to a subpoena.
4. When law enforcement requires For example, we may have to use or disclose your PHI in
response to a
5. When public health activities require For example, we may have to use or disclose your PHI
to report to a government official an adverse reaction that you have to a medication.
6. When health oversight activities require For example, we may have to provide information to
assist the government in conducting an investigation or inspection of a health care provider
or organization.
7. To avert a serious threat to health or For example, we may have to use or disclose your PHI
to avert a serious threat to the health or safety of others. However, any such disclosures will
only be made to someone able to prevent the

8. For specialized government If you are in the military, we may have to use or disclose your
PHI for national security purposes, including protecting the President of the United States or
conducting intelligence operations.
9. To remind you about appointments and to inform you of health related benefits or For
example, we may have to use or disclose your PHI to remind you about your appointments,
or to give you information about treatment alternatives, other health care services, or other
health care benefits that we offer that may be of interest to you.
C. Certain Uses and Disclosures Require You to Have the Opportunity to

1. Disclosures to Family, Friends, or We may provide your PHI to a family member, friend, or
other person that you indicate is involved in your care or the payment for your health care,
unless you object in whole or in part. The opportunity to consent may be obtained
retroactively in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not
described in sections III A, B, and C above, we will need your written authorization before using or
disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later
revoke such authorization in writing to stop any future uses and disclosures (to the extent that we
haven’t taken any action in reliance on such authorization) of your PHI by

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

You have the following rights with respect to your PHI:

A. The Right to Request Restrictions on our Uses and Disclosures. You have the right to request
restrictions or limitations on our uses or disclosures of your PHI to carry out our treatment, payment,
or health care operations. You also have the right to request that we restrict or limit disclosures of
your PHI to family members or friends or others involved in your care or who are financially
responsible for your care. Please submit such requests to us in writing. We will consider your
requests, but we are not legally required to accept If we do accept your requests, we will put them in
writing and we will abide by them, except in emergency situations. However, be advised, that you
may not limit the uses and disclosures that we are legally required to make.

B. The Right to Choose How We Send PHI to You. You have the right to request that we send
confidential information to you at an alternate address (for example, sending information to your
work address rather than your home address) or by alternate means (for example, email instead of
regular mail). We must agree to your request so long as it is reasonable and you specify how or
where you wish to be contacted, and, when appropriate, you provide us with information as to how
payment for such alternate communications will be handled. We may not require an explanation

from you as to the basis of your request as a condition of providing communications on a confidential
basis.

C. The Right to Inspect and Receive a Copy of Your In most cases, you have the right to inspect and
receive a copy of the PHI that we have on you, but you must make the request to inspect and
receive a copy of such information in writing. If we don’t have your PHI but we know who does, we
will tell you how to get it. We will respond to your request within 30 days of receiving your written
request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our
reasons for the denial and explain your right to have our denial reviewed. If you request copies of
your PHI, we will charge you no more than $.25 for each page. Instead of providing the PHI you
requested, we may provide you with a summary or explanation of the PHI as long as you agree to
that and to the cost in advance.

D. The Right to Receive a List of the Disclosures We Have Made. You have the right to receive a list
of instances, i.e., an Accounting of Disclosures, in which we have disclosed your The list will not
include disclosures made for our treatment, payment, or health care operations; disclosures made to
you; disclosures you authorized; disclosures incident to a use or disclosure permitted or required by
the federal privacy rule; disclosures made for national security or intelligence; disclosures made to
correctional institutions or law enforcement personnel; or, disclosures made before April 14, 2003.
We will respond to your request for an Accounting of Disclosures within 60 days of receiving such
request. The list we will give you will include disclosures made in the last six years unless you
request a shorter time. The list will include the date the disclosure was made, to whom the PHI was
disclosed (including their address, if known), a description of the information disclosed, and the
reason for the disclosure. We will provide the list to you at no charge, but if you make more than one
request in the same year, we may charge you a reasonable, cost based fee for each additional
request.
E. The Right to Amend Your If you believe that there is a mistake in your PHI or that a piece of
important information is missing, you have the right to request that we correct the existing
information or add the missing information. You must provide the request and your reason for the
request in writing. We will respond within 60 days of receiving your request to correct or update your
PHI. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us,
(iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the
reasons for the denial and explain your right to file a written statement of disagreement with the
denial. If you don’t file one, you have the right to request that your request and our denial be
attached to all future disclosures of your PHI. If we approve your request, we will make the change
to your PHI, tell you that we have done it, and tell others that need to know about the change to your
PHI.

F. The Right to Receive a Paper Copy of this You have the right to receive a paper copy of this
notice even if you have agreed to receive it via email.

V. FILING A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you think that we may have violated your privacy rights, or you disagree with a decision we made
about access to your PHI, you may file a complaint with the person listed in Section Vl below. You
also may send a written complaint to the Secretary of the Department of Health and Human Services
at 200 Independence Avenue S.W., Washington, D.C. 20201.
We will take no retaliatory action against you if you file a complaint about our privacy practices.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN
ABOUT OUR PRIVACY PRACTICES

If you have any questions about this notice or any complaints about our privacy practices, or would
like to know how to file a complaint with the Secretary of the Department of Health and Human
Services, please contact us at: 888-541-1167.
ACKNOWLEDGEMENT AND CONSENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that we have given
to you. Our Notice of Privacy Practices provides information about how we may use and disclose
your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change the notice, you may obtain a copy
of the revised notice from us by contacting us at 818-916-6869 or in person at our facility.

If you have any questions about our Notice of Privacy Practices, please contact us at: 818-916-6869.
I acknowledge receipt of the Notice of Privacy Practices of Warner Park Recovery Center in my
Client Handbook.

I understand that this facility is a part of an organized healthcare arrangement that includes various
third party payers. With my consent; I give permission for these entities to share my health
information for purposes of treatment, billing and other healthcare operations.

I understand that there is a publicly posted copy of this organization’s notice of privacy practices that
describes how my health information is used and shared. I understand that this facility has the right

to change this notice at any time and I may obtain a current copy by contacting the facility’s
administration office.

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