Safety, Quality, Compliance

Non-Discrimination Notice

Southeast Missouri Behavioral Health complies with applicable Federal civil rights laws and does not discriminate against clients/patients on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP). Southeast Missouri Behavioral Health does not exclude people or treat them less favorably because of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP).

Southeast Missouri Behavioral Health:

• Provides individuals with disabilities (including individuals’ companions with disabilities) reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:
  • Qualified interpreters, including American Sign Language
  • Written information in other formats (large print, audio, accessible electronic formats, other formats).
• Provides free language assistance services to individuals whose primary language is not English (including individuals’ companions with limited English proficiency), which may include:
  • Qualified interpreters
  • Electronic and written translated documents

If you need appropriate auxiliary aids and services or language assistance services, contact the Compliance and Integrity department at 855-450-5770 or LanguageServices@LiveBrightli.org.

If you need reasonable modifications, contact your provider and/or the Section 1557 Coordinator, Leah Barber at 855-450-5770 or BrightliCompliance@LiveBrightli.org.

If you believe that Southeast Missouri Behavioral Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws, you can file a complaint/grievance by contacting the Section 1557 Coordinator, Leah Barber, via:

• Phone: 855-450-5770
• Email: BrightliCompliance@LiveBrightli.org
• Mail: Section 1557 Coordinator c/o Brightli Compliance and Integrity Department, 1111 S. Glenstone Ave, Springfield, MO 65804

You can file a grievance in person or by mail or email. If you need help filing a grievance, the Section 1557 Coordinator, Leah Barber, is available to help you.

You can also file a civil rights complaint with applicable state agencies and/or the U.S. Department of Health and Human Services, Office for Civil Rights:

• Electronically through the Office for Civil Rights Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
• Mail: U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. – 509F, Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This notice is available at Southeast Missouri Behavioral Health’s website: semobh.org.

Language Assistance and Auxiliary Aids and Services Available

This Agency’s program is designed to help you recover from a life-threatening illness that affects a large number of people in our society. Your admission to this program is essentially a contract in which we work together for a common goal. As a client, you have both rights and responsibilities.

The following Statement of Rights available to all clients is to assure that such rights are assured, also, the following policies and procedures are designed to enhance and to protect the human, civil, constitutional and statutory rights of each individual client. Each client in treatment shall be entitled to the following rights and privileges without limitation.

• To have private visits from an attorney, physician, or clergyman at reasonable times.
• To correspond by sealed mail with officials of the Department of Mental Health and other state departments, with an attorney, a court, or the Board of Directors of the Center and the Chief Executive Officer of the Center.
• To have humane care and competent treatment.
• To have as far as possible within the capabilities of the Agency, its equipment and personnel, available as well as medical care and treatment in accordance with the highest standards accepted in medical practice.
• To have safe and clean surroundings.
• To receive prompt evaluation, care and treatment by professional competent personnel.
• To have their individual treatment plan (rehabilitation plan) explained to them.
• To be treated with dignity and addressed in a respectful, age appropriate manner.
• To be the subject of an experiment only with consent or the consent of a person legally authorized to act and such shall be consistent and in accordance with institutional review boards of the Department of Health and Human Services as well as the Department of Mental Health and other so duly qualified and recognized bodies.
• To be examined by a private physician at the client’s own expense.
• To be evaluated and cared for in the least restrictive environment.
• To refuse hazardous treatment unless ordered by a court.
• To request and receive a second opinion before hazardous treatment except in an emergency.
• To have records kept confidential and such records may not be released without the prior written consent of the client in accordance with state and federal laws.
• To have the same legal rights and responsibilities as any other citizen, unless otherwise stated by law.
• To not be denied admission or services because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran, or military status.
• And to be free from abuse, neglect, corporal punishment and other mistreatment such as humiliation, threats or exploitation.
• Any limitations of the client’s rights and privileges listed immediately above must be justified in the client file/record and reviewed by the Director and Chief Executive Officer of Southeast Missouri Behavioral Health. Clients shall be informed of their rights in language the client understands.

Clients may correspond directly with the Clients’ Rights Monitor by writing:

Missouri Department of Mental Health
Clients’ Rights Monitor
1706 E. Elm, P.O. Box 687
Jefferson City, Missouri 65102

1-800-364-9687

Centerstone Affiliated Covered
Entity Notice of Privacy Practices

 This notice describes:

• How health, mental health and substance use disorder information about you may be used and disclosed.
• How you may get access to your health information.
• Your rights with respect to your health information.
• How to file a complaint concerning a violation of the privacy or security of your health information, or of your rights concerning your information.
• You have a right to a copy of this notice (in paper or electronic form) and to discuss it with the compliance office listed at the end of this notice if you have any questions.

Please review it carefully.

 AFFILIATED ENTITIES COVERED BY THIS NOTICE

This Notice of Privacy Practices (“Notice”) covers an Affiliated Covered Entity (“ACE”). An ACE is a group of Covered Entities that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (HIPAA). Certain ACE members may also be considered a Substance Use Disorder (SUD) Treatment Program, which is governed by the Confidentiality of Substance Use Disorder Records regulations set forth in 42 CFR Part 2. These members have designated themselves as a single SUD Treatment Program for compliance with 42 CFR Part 2. When this Notice refers to “Centerstone ACE” and/or “Centerstone’: it is referring collectively to the Ccntcrstonc ACE. For a current list of Ccntcrstonc ACE members, please visit http://www.ccntcrstonc.org or contact the Compliance Office listed at the end of this notice.

Centerstone ACE is committed to protecting the privacy and security of your medical, mental heath and substance abuse information. We are required by law to maintain the privacy and security of your heath information, to provide you this notice and to comply with its terms. The privacy practices in this Notice apply to all staff, students, volunteers, contract staff and business associates and/or qualified service organizations.

Centerstone and certain affiliated organizations participate in one or more Organized Health Care Anangements (OHCA) as defined by the HIP AA Privacy Rule. An OHCA allows participating entities to share health information for joint quality improvement activities and other heath care operations. For a current list of OHCA participants please visit our website at http://www.centerstone.org or contact the Compliance Office listed at the end of this notice.

As part of these arrangements, your health information may be shared among OHCA participants or through a health information exchange only when necessary for treatment or health care operations. Health care operations may include activities such as quality assessment, clinical review, improving referral management, and enhancing care through technology (for example, geocoding your address to improve service delivery).

Your health information may include past, present, and future medical information, as permitted by law. All disclosures will comply with the HIPAA Privacy Rule and other applicable laws. You may revoke your consent in writing at any time; however, information already shared under your prior consent cannot be retracted. Upon request, you may receive a list of entities to which your information has been disclosed.

YOUR RIGHTS

When it comes to your health information, you have certain rights that apply to your records including substance use disorder (SUD) treatment records. This section explains your rights and some of our responsibilities to help you.

Review your record or get an electronic copy or paper copy of your medical records

• You can ask to see or get an electronic or paper copy of your health information we maintain about you. You may send your written request to the Compliance Office listed at the end of this Notice. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable cost-based fee.
• You may also request to review your medical record. You will be given access to your records for review along with your treatment provider
• We may provide a patient portal as one option for patients to electronically access their health information. If we have a patient portal, you may request access by contacting your health care provider. There is no fee for you to access health information through our patient portal.

Ask us to correct your medical record

• You may ask us to correct health information about you that you think is incomplete or incorrect. You may do this by submitting your request in writing to the Compliance Office listed at the end of this Notice. You must include a reason for the request.
• We may say “no” to your request, but we will tell you why in writing within 60 days, for example: The information was not created by us;
  • The information is not part of the information kept by or for Centerstone;
  • The information is not part of the information which you would be permitted to review and copy; or
  • The information in the record is accurate and complete.

Request confidential communications

• You may ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• To request confidential communications, you must make your request in writing to the Compliance Office listed at the end of this Notice.
• We will not ask you for the reason for your request.
• Your request must specify how or where you wish to be contacted.
• We will generally approve reasonable requests.

Ask us to limit what we use or share

• You may ask us not to use or share certain health information for treatment, payment or our operations.
• We are not required to agree with your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full and before the item or service is provided, you may ask us not to share that information with your insurer for the purpose of payment or our operations. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared your health information

• You may ask for a list (accounting) of the times we’ve shared your information for 6 years prior to the date you ask and why we share it.
• We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
• We will provide one (1) accounting a year free of charge but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of the privacy notice

• You may ask for, and we will promptly provide you with a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take action.

File a complaint if you feel your rights are violated

• You may file a complaint if you feel we have violated your rights by contacting us using the information on the last page of this Notice.
• You can file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington , D.C., calling 1-877-696-6775, or by visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you may 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, talk to us. Tell 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 friend, 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 go ahead and share your information if we believe it is in your best interest.
• We may also share information when needed to lessen a serious or imminent threat to health or safety.
• Centerstone does not create or maintain a facility directory.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes.
• Sale of your health information.
• Most sharing of psychotherapy notes, to the extent such exist.

In the case of fundraising:

• We may contact you for fundraising efforts, but you may tell us not to contact you again by contacting the Compliance Office listed at the end of this Notice.
• If you opt out of fundraising communications, it will not affect your care.

EXERCISING YOUR RIGHTS/ MAKING YOUR CHOICES

Any requests and/or exercise of your rights, as described in this Notice, may be made by providing written notice to the Compliance Office listed at the end of this Notice.

• To Treat You: If permitted by applicable state and federal law, we may use your health information and share it with professionals who are treating you.
• To Bill for Services: If permitted by applicable state and federal law, we will use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
• To Run Our Organization: If permitted by applicable state and federal law, we may use and share your health information to run Centerstone and improve the quality of your care; to respond to audits and investigation; for licensing purposes. Example: We use health information about you to manage your treatment and services; to evaluate our performance in providing services.

OTHER USES AND DISCLOSURES

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet any conditions in applicable law before we may share your information for these purposes. For more information, visit: http://www.hhs.gov /ocr/privacy/hipaa /understanding/consumers/index.html

Help with public health and safety issues

If permitted by applicable state and federal law, we may 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 someone’s health or safety as long as: The disclosure is made to someone able to help prevent the threat, and
  • Only under the conditions described by applicable state law.

Research

• If permitted by applicable state and federal law, we may use or share your information for health research, provided certain conditions are met.

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 wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• If permitted by applicable state and federal law, we may share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• If permitted by applicable state and federal law, we may share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

If permitted by applicable state and federal law, we may use or share health information about you:

• For workers’ compensation claims;
• For law enforcement purposes with a law enforcement official;
• With health oversight agencies for activities authorized bylaw;
• For special government functions, such as military and veterans authority, national security, and presidential protective services.

Respond to lawsuits and legal actions

• We may share health information about you in response to court or administrative orders as permitted by applicable federal and state law.

Communication regarding inmates in correctional facilities

If you are an inmate in a correctional facility or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official if permitted by applicable federal and state law and the release of the information is necessary:

• For the correctional facility or institution to provide you with health care; or
• To protect your health or safety or the health or safety of others; or
• For the safety and security of the correctional facility or institution.

Communications with family

• If you receive services in an inpatient or residential setting, we may, as allowed by applicable federal and state law, disclose to a family member or other relative, close person friend or any other person you identify, health information relevant to that person’s involvement to your care or payments related to your care.

National Security Activities for Protection of the President or Other Officials

• We may share your health information for national security activities for protection of the President or other officials if permitted by federal and state law.

Military Command Authorities

• We may share your health information with appropriate military command authorities if you are a member of the armed forces and sharing your information is permitted by federal and state law.

Health Information Exchange (HIE)

• We may use a Health information Exchange (HIE) to exchange electronic health information about you with other healthcare providers or entities that are not part of our healthcare system.
• Health information exchanged between providers or entities may be stored in their own systems and can be used for the purposes described in this Notice, to coordinate your care and as permitted by law.
• Unless prohibited by law, you are automatically opted in to such HIEs. If you wish to opt out, you must make a written request, which we will comply with unless disclosure is required by law. If you opt out of participating in these HIEs, your health information will no longer be provided to other health care entities through the HIE. However, your decision does not affect the health information that was exchanged prior to the time you opted out of participation.
• Note that certain sensitive information requires your consent prior to disclosure for these purposes, such as Part 2 Records, and will not be shared though the HIE unless we have obtained your consent as required by applicable law.

Minors

• A minor’s health information will be disclosed to their parents or legal guardians acting as personal representative, unless prohibited by law or in circumstances where the law permits us to withhold the information, such as to prevent harm to the minor or another person or in cases of suspected child abuse or neglect.

Breach Notification Purposes

• If for any reason there is an unsecured breach of your protected health information, we will use the contact information you have provided us with to notify you of the breach, as required by law. In addition, your protected health information may be disclosed as a part of the breach notification and reporting process.

Business Associates

• We may disclose your health information to Business Associates and/or Qualified Service Organizations contracted by us to perform services on our behalf, which may involve receipt, use or disclosure of your health information.
• All of our Business Associates must agree to (i) protect the privacy of your health information; (ii) use and disclose the health information only for the purposed for which Business Associate was engaged; (iii) if receiving SUD information, be bound by 42 CFR Part 2 and, if necessary, resist in judicial proceedings any efforts to obtain access to patient records except as permitted by law.
• We may also share your health information with a Business Associate who will remove information that identifies you so that the remaining information can be used or disclosed for purposed outside of this Notice.

SUBSTANCE USE DISORDER TREATMENT RECORDS

Centerstone offers substance use disorder (SUD) treatment programs and is required to comply with the federal Confidentiality of Substance Use Disorder Patient Records laws and regulations (42 CFR Part 2) that place strict limitations on how these records may be used or disclosed for individuals who are receiving any type of treatment related to substance use disorders.

Substance Use Disorder (SUD) is a condition where a person keeps using a drug or substance even though it’s causing serious problems in their life. These problems can include trouble controlling their use, issues at work or in relationships, using in dangerous situations, and physical effects like needing more of the substance to feel the same effect or having withdrawal symptoms when they stop. This definition does not include tobacco or caffeine use.

We will obtain your written consent to use and disclose your SUD records unless we are permitted to use and disclose SUD records without your written consent consistent with 42 CFR Part 2. The following categories describe the ways that we may use and disclose your SUD records without your written consent under 42 CFR Part 2.

Medical Emergencies

• We may disclose your SUD records to medical personnel to the extent necessary to meet a bona fide medical emergency in which the your prior written consent cannot be obtained or in which we are closed and unable to provide services or obtain your prior written consent during a temporary state of emergency declared by a state or federal authority as the result of a natural or major disaster, until such time as we resume operations.
• We will obtain your authorization prior to disclosing your information for non-emergency treatment.

Food and Drug Administration (FDA)

• We may disclose your SUD records to medical personnel of the Food and Drug Administration (FDA) who assert a reason to believe that your health may be threatened by an error in the manufacturer, labeling, or sale of a product under the FDA jurisdiction, and that your SUD records will be used for the exclusive purpose of notifying you or your physicians of potential danger.

Research

• Under certain circumstances, we may use and disclose your SUD records without your consent for research purposes.
• Generally, we would first obtain your written consent; however, in certain circumstances, we may be permitted to use or disclose your SUD records for research purposes without your consent to the extent permitted by HIPAA, FDA and HHS regulations related to human subject research where a waiver of consent has been granted.

Management and Financial Audits and Program Evaluation

• Under certain circumstances we may use or disclose your SUD records for purposes of the performance of certain program financial and management audits and evaluations.
• For example, we may disclose your identifying information to any federal, state, or local government agency that provides financial assistance to the Part 2 program or is authorized by law to regulate the activities of Part 2 program.
• We may also use or disclose your identifying information to qualified personnel who are performing audit or evaluation functions on behalf of any person that provides financial assistance to the Part 2 program, which is a third-party payer or health plan covering you in your treatment, or which is a quality improvement organization (QIO), performing QIO review, the contractors, subcontractors, or legal representatives of such person or QIO, or an entity with direct administrative control over our program.

Fundraising

• Consistent with provisions elsewhere in this Notice, we may also use or disclose your

Public Health

• We may use or disclose to a public health authority your SUD records for public health purposes. However, the contents of the information from the SUD records disclosed will be de-identified in accordance with the requirements of the HIPAA regulations, such that there will be no reasonable basis to believe that the information can be used to identify you.

Marketing Purposes

• Disclosures for marketing purposes which result in our receiving financial payment from a third party whose product or services is being marketed will require your written authorization. This does not include compensation that merely covers our cost of reminding you to take and refill your medication or otherwise communicate about a drug or biologic that is currently prescribed to you.
• However, we may use or disclose your PHI without your authorization to send you information about alternative medical treatments, our own programs or about health-related products and services that may be of interest to you, provided that we do not receive financial remuneration for making such communications. For example, we may use your PHI to assess your eligibility and propose newly available treatments.
• When we see you face-to-face, we may also use your PHI without your authorization to encourage you to maintain a healthy lifestyle and get recommended tests, suggest that you participate in a disease management program, provide you with promotional gifts of nominal value, or tell you about government sponsored health programs.

Sale of PHI

• For example, we cannot share your PHI in exchange for direct or indirect remuneration constituting a sale of PHI under HIPAA without your prior authorization.

WE MAY USE AND DISCLOSE YOUR SUD RECORDS WHEN YOU GIVE YOUR WRITTEN CONSENT SATISFYING THE REQUIREMENTS OF PART 2.

Designated person or entities

• We may use and disclose your SUD records in accordance with the consent to any person or category of persons identified or generally designated in the consent. For example, if you provide written consent naming your spouse or a healthcare provider, we will share your health information with them as outlined in your consent.

Single Consent for Treatment, Payment or Healthcare Operations

• We may also use and disclose your SUD records when the consent provided is a single consent for all future uses and disclosures for treatment, payment, and healthcare operations, as permitted by the HIPAA regulations, until such time you revoke such consent in writing.

Central Registry or Withdrawal Management Program

• We may disclose your SUD records to a central registry or to any withdrawal management or treatment program for the purposes of preventing multiple enrollments, with your written consent. For instance, if you consent to participating in a drug treatment program, we can disclose your information to the related program to coordinate care and avoid duplicate enrollment.

Criminal Justice System

• We may disclose information from your SUD records to those persons within the criminal justice system who have made your participation in the Part 2 program a condition of the disposition of any criminal proceeding against you.
• The written consent must state that it is revocable upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event. The time or occurrence upon which consent becomes revocable may be no later than the final disposition of the conditional release or other action in connection with which consent was given.
• For example, if you consent, we can inform a court-appointed officer about your treatment status as part of legal agreement or sentencing conditions.

PDMPs

• We may report any medication prescribed or dispensed by us to the applicable state prescription drug monitoring program if required by applicable state law.
• We will first obtain your consent to a disclosure of SUD records to a prescription drug monitoring program prior to reporting of such information.

Civil, administrative, criminal, or legislative proceedings, subpoenas, and court orders

• Any Part 2 Record, or testimony relaying the content of such SUD records, shall not be used or disclosed in a civil, administrative, criminal, or legislative proceeding against you unless you provide specific written consent (separate from any other consent) or a court issues an appropriate order.
• Your SUD records will only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you, the Centerstone ACE or other holder of the Part 2 Record in accordance with Part 2.
• A court order authorizing use or disclosure of SUD records must be accompanied by a subpoena or other similar legal mandate compelling disclosure before the SUD records may be used or disclosed.

Exceptions

• 42 CFR Part 2 does not protect health information about a crime committed on our premises or against any of our personnel or about any threat to commit such crime.
• 42 CFR Part 2 also does not prohibit the disclosure of health information by us to report suspected child abuse or neglect under state law to appropriate state or local authorities.
• The restrictions on use and disclosure in 42 CFR Part 2 do not apply to communications of SUD records between or among personnel having a need for them in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of patients with substance use disorders if the communications are within the program (or with an entity that has direct administrative control over the program the communications between a part 2 program) and to communications of SUD records to a qualified service organization if needed by the qualified service organization to provide services to or on behalf of the Centerstone ACE (similar to provisions herein regarding Business Associates).

To the extent applicable state law is even more stringent than 42 CFR Part 2 on how we may use or disclose your health information, we will comply with the more stringent state law.

Psychotherapy/SUD Counseling Notes: Psychotherapy/SUD Counseling notes are defined as notes taken to analyze a conversation during a session that are maintained separate from your health record. We do not maintain these types of notes.

NOTICE OF REDISCLOSURE

PHI that is disclosed pursuant to this Notice may be subject to redisclosure by the recipient and no longer protected by HIPAA. Laws applicable to the recipient may limit their ability to use and disclose

the PHI received, such as if they are another covered entity subject to HIPAA or a program or entity subject to 42 CFR Part 2.

Please note that if SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI.

OUR RESPONSIBILITIES

Privacy and Security: We are required by law to maintain the privacy and security of your protected health information.

Breach Notification: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your health information. In no event will notification be more than 60 days from the date of the breach.

Compliance: We must follow the duties and privacy practices described in this Notice and give you a copy of it.

Revoking your Authorization: We will not use or share your health information other than as described here unless you tell us, in writing, that we may do so. If you tell us that we may, you have the right to change your mind at any time by telling us in writing that you have changed your mind. This will not apply to disclosures that have already occurred with your authorization.

For more information regarding your rights and our responsibilities please contact the Compliance & Privacy Officer for your service location or visit: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF THIS NOTICE

We may change the terms of this Notice, and the changes will apply to all information we have about you as well as any information we receive in the future. The new Notice will be available upon request, in our facilities, and on our web site: http://www.centerstone.org. Additionally, we will prominently display a copy of the current notice in common areas within Centerstone’s facilities. Each time you register at or are admitted to Centerstone for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

HOW TO MAKE A COMPLAINT IF YOU FEEL YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED

If you believe your privacy rights have been violated, you may file a complaint with Centerstone or with the Secretary of the Department of Health and Human Services. Centerstone will never ask you to waive your right to complain.

To file a complaint with Centerstone please contact the Compliance Office listed at the end of this Notice.

To file a complaint with the Secretary of the Department of Health and Human Services, by sending a letter to 200 Independence Avenue, S.W., Washington, D.

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT!

CONTACT INFORMATION

For questions and concerns regarding client privacy, your rights under the federal privacy standards, and our privacy practices please email: NPP.Questions@centerstone.org or call toll-free (855) 450-5770.

Non-Discrimination Notice

Adult and Child Health complies with applicable Federal civil rights laws and does not discriminate against clients/patients on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP). Adult and Child Health does not exclude people or treat them less favorably because of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP).

Adult and Child Health:

• Provides individuals with disabilities (including individuals’ companions with disabilities) reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:
  • Qualified interpreters, including American Sign Language
  • Written information in other formats (large print, audio, accessible electronic formats, other formats).
• Provides free language assistance services to individuals whose primary language is not English (including individuals’ companions with limited English proficiency), which may include:
  • Qualified interpreters
  • Electronic and written translated documents

If you need appropriate auxiliary aids and services or language assistance services, contact the Compliance and Integrity department at 855-450-5770 or LanguageServices@LiveBrightli.org.

If you need reasonable modifications, contact your provider and/or the Section 1557 Coordinator, Leah Barber at 855-450-5770 or BrightliCompliance@LiveBrightli.org.

If you believe that Adult and Child Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws, you can file a complaint/grievance by contacting the Section 1557 Coordinator, Leah Barber, via:

• Phone: 855-450-5770
• Email: BrightliCompliance@LiveBrightli.org
• Mail: Section 1557 Coordinator c/o Brightli Compliance and Integrity Department, 1111 S. Glenstone Ave, Springfield, MO 65804

You can file a grievance in person or by mail or email. If you need help filing a grievance, the Section 1557 Coordinator, Leah Barber, is available to help you.

You can also file a civil rights complaint with applicable state agencies and/or the U.S. Department of Health and Human Services, Office for Civil Rights:

• Electronically through the Office for Civil Rights Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
• Mail: U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. – 509F, Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This notice is available at Adult and Child Health’s website: adultandchild.org.

Language Assistance and Auxiliary Aids and Services Available

Client Rights and Responsibilities

To provide you with quality services that meet your needs, it is important that you participate in your treatment and that you understand and exercise your rights and responsibilities listed below.

RIGHTS | You have the right to:

• Considerate, respectful, and safe care and protection from harm, abuse, neglect, and exploitation with recognition of your personal dignity. 
• Person centered and family-centered care which recognizes individual cultural needs. 
• Access medically appropriate and available treatment regardless of race, color, religion, sex, sexual orientation, gender identity or status as transgender, national origin, age, military service, socioeconomic status, or disability. 
• Freedom of choice or to request a change in your provider at A&C or designated partner organizations. 
• Privacy regarding your involvement with A&C to the extent provided by federal and state law. * 
• Receive information about the identity, education, licensure, and professional status of individuals involved in providing your services. 
• Obtain information regarding your care, in compliance with applicable laws. • Review and receive an explanation of the bill for services rendered by A&C staff. 
• Participate in making treatment decisions as well as the right to a clear and complete description of recommended services. 
• Pain screening. 
• Be informed of outcomes of any treatment, care, or service whenever those outcomes differ significantly from the anticipated outcomes. 
• Express concerns, grievances, or complaints regarding any aspect of your care. 
• Give or withhold informed consent. ** 
• Receive information in terms and languages you understand. 
• Contact and consult with legal counsel and private practitioners of your choice at your expense. 
• Access protective and advocacy services. 
• Never be denied service based solely on inability to pay. A sliding fee discount schedule is available for those who qualify.

*At times state and/or federal statutes require or permit the release of information without a signed release of information and to allow for emergency treatment without consent in certain circumstances. Please see A&C Notice of Privacy Practices.
**If you are court ordered to participate in treatment and wish to refuse, you may petition the committing court for consideration.

RESPONSIBILITIES | You have the responsibility to:

• Provide accurate and complete information about your present concerns, past illnesses, prior treatments, and other matters relating to your care. 
• Be an active and cooperative partner in following your treatment plan, including keeping appointments and notifying clinicians of necessary cancellations. 
• Ask questions regarding your treatment if you do not understand and / or agree with the recommendations of A&C staff. 
• Pay all charges for treatment services not covered by insurance in a timely manner. 
• Inform A&C if and when you choose to receive mental health services elsewhere. 
• Abstain from being under the influence of alcohol or other non-prescribed mood-altering substances while on A&C premises. 
• Be considerate of the rights and concerns of other clients and A&C staff. 
• Respect the confidentiality and privacy of other persons seen at A&C. 
• Never carry weapons of any kind on A&C premises. 
• Provide supervision of any minor children who may accompany you to A&C. 
• Abstain from using any tobacco products while on any A&C property, inside buildings and outside grounds.

If you are dissatisfied with your services, have a concern about your treatment or safety, or feel that your privacy or confidentiality has not been honored, please call the Care Experience Hotline at (317) 893-0319.

If you do not want to speak to someone directly, you may fill out a “Client Grievance/Complaint” form which is located in each lobby. You also have the right to contact the DMHA Consumer Service Line at (800) 901-1133 or The Joint Commission Complaint Line at: (800) 994-6610 or Indiana Disability Rights at (800) 622-4845.

Adult & Child 24-Hour Emergency Assistance

Behavioral health needs and medical concerns can be addressed 24/7 by contacting the numbers below.

Contact

(317) 882-5122

Toll free: (877) 882-5122

Centerstone Affiliated Covered Entity Notice of Privacy Practices

This notice describes:

• How health, mental health and substance use disorder information about you may be used and disclosed.
• How you may get access to your health information.
• Your rights with respect to your health information.
• How to file a complaint concerning a violation of the privacy or security of your health information, or of your rights concerning your information.
• You have a right to a copy of this notice (in paper or electronic form) and to discuss it with the compliance office listed at the end of this notice if you have any questions.

Please review it carefully.

Effective Date: May 1, 2026

AFFILIATED ENTITIES COVERED BY THIS NOTICE

This Notice of Privacy Practices (“Notice”) covers an Affiliated Covered Entity (“ACE”). An ACE is a group of Covered Entities that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (HIPAA). Certain ACE members may also be considered a Substance Use Disorder (SUD) Treatment Program, which is governed by the Confidentiality of Substance Use Disorder Records regulations set forth in 42 CFR Part 2. These members have designated themselves as a single SUD Treatment Program for compliance with 42 CFR Part 2. When this Notice refers to “Centerstone ACE” and/or “Centerstone’: it is referring collectively to the Ccntcrstonc ACE. For a current list of Ccntcrstonc ACE members, please visit www.ccntcrstonc.org or contact the Compliance Office listed at the end of this notice.

Centerstone ACE is committed to protecting the privacy and security of your medical, mental heath and substance abuse information. We are required by law to maintain the privacy and security of your heath information, to provide you this notice and to comply with its terms. The privacy practices in this Notice apply to all staff, students, volunteers, contract staff and business associates and/or qualified service organizations.

Centerstone and certain affiliated organizations participate in one or more Organized Health Care Anangements (OHCA) as defined by the HIP AA Privacy Rule. An OHCA allows participating entities to share health information for joint quality improvement activities and other heath care operations. For a current list of OHCA participants please visit our website at www.centerstone.org or contact the Compliance Office listed at the end of this notice.

As part of these arrangements, your health information may be shared among OHCA participants or through a health information exchange only when necessary for treatment or health care operations. Health care operations may include activities such as quality assessment, clinical review, improving referral management, and enhancing care through technology (for example, geocoding your address to improve service delivery).

Your health information may include past, present, and future medical information, as permitted by law. All disclosures will comply with the HIPAA Privacy Rule and other applicable laws. You may revoke your consent in writing at any time; however, information already shared under your prior consent cannot be retracted. Upon request, you may receive a list of entities to which your information has been disclosed.

YOUR RIGHTS

When it comes to your health information, you have certain rights that apply to your records including substance use disorder (SUD) treatment records. This section explains your rights and some of our responsibilities to help you.

Review your record or get an electronic copy or paper copy of your medical records

• You can ask to see or get an electronic or paper copy of your health information we maintain about you. You may send your written request to the Compliance Office listed at the end of this Notice. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable cost-based fee.
• You may also request to review your medical record. You will be given access to your records for review along with your treatment provider
• We may provide a patient portal as one option for patients to electronically access their health information. If we have a patient portal, you may request access by contacting your health care provider. There is no fee for you to access health information through our patient portal.

Ask us to correct your medical record

• You may ask us to correct health information about you that you think is incomplete or incorrect. You may do this by submitting your request in writing to the Compliance Office listed at the end of this Notice. You must include a reason for the request.
• We may say “no” to your request, but we will tell you why in writing within 60 days, for example: The information was not created by us;
  • The information is not part of the information kept by or for Centerstone;
  • The information is not part of the information which you would be permitted to review and copy; or
  • The information in the record is accurate and complete.

Request confidential communications

• You may ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• To request confidential communications, you must make your request in writing to the Compliance Office listed at the end of this Notice.
• We will not ask you for the reason for your request.
• Your request must specify how or where you wish to be contacted.
• We will generally approve reasonable requests.

Ask us to limit what we use or share

• You may ask us not to use or share certain health information for treatment, payment or our operations.
• We are not required to agree with your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full and before the item or service is provided, you may ask us not to share that information with your insurer for the purpose of payment or our operations. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared your health information

• You may ask for a list (accounting) of the times we’ve shared your information for 6 years prior to the date you ask and why we share it.
• We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
• We will provide one (1) accounting a year free of charge but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of the privacy notice

• You may ask for, and we will promptly provide you with a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take action.

File a complaint if you feel your rights are violated

• You may file a complaint if you feel we have violated your rights by contacting us using the information on the last page of this Notice.
• You can file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington , D.C., calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you may 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, talk to us. Tell 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 friend, 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 go ahead and share your information if we believe it is in your best interest.
• We may also share information when needed to lessen a serious or imminent threat to health or safety.
• Centerstone does not create or maintain a facility directory.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes.
• Sale of your health information.
• Most sharing of psychotherapy notes, to the extent such exist.

In the case of fundraising:

• We may contact you for fundraising efforts, but you may tell us not to contact you again by contacting the Compliance Office listed at the end of this Notice.
• If you opt out of fundraising communications, it will not affect your care.

EXERCISING YOUR RIGHTS/ MAKING YOUR CHOICES

Any requests and/or exercise of your rights, as described in this Notice, may be made by providing written notice to the Compliance Office listed at the end of this Notice.

• To Treat You: If permitted by applicable state and federal law, we may use your health information and share it with professionals who are treating you.
• To Bill for Services: If permitted by applicable state and federal law, we will use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
• To Run Our Organization: If permitted by applicable state and federal law, we may use and share your health information to run Centerstone and improve the quality of your care; to respond to audits and investigation; for licensing purposes. Example: We use health information about you to manage your treatment and services; to evaluate our performance in providing services.

OTHER USES AND DISCLOSURES

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet any conditions in applicable law before we may share your information for these purposes. For more information, visit: www.hhs.gov /ocr/privacy/hipaa /understanding/consumers/index.html

Help with public health and safety issues

If permitted by applicable state and federal law, we may 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 someone’s health or safety as long as: The disclosure is made to someone able to help prevent the threat, and
  • Only under the conditions described by applicable state law.

Research

• If permitted by applicable state and federal law, we may use or share your information for health research, provided certain conditions are met.

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 wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• If permitted by applicable state and federal law, we may share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• If permitted by applicable state and federal law, we may share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

If permitted by applicable state and federal law, we may use or share health information about you:

• For workers’ compensation claims;
• For law enforcement purposes with a law enforcement official;
• With health oversight agencies for activities authorized bylaw;
• For special government functions, such as military and veterans authority, national security, and presidential protective services.

Respond to lawsuits and legal actions

• We may share health information about you in response to court or administrative orders as permitted by applicable federal and state law.

Communication regarding inmates in correctional facilities

If you are an inmate in a correctional facility or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official if permitted by applicable federal and state law and the release of the information is necessary:

• For the correctional facility or institution to provide you with health care; or
• To protect your health or safety or the health or safety of others; or
• For the safety and security of the correctional facility or institution.

Communications with family

• If you receive services in an inpatient or residential setting, we may, as allowed by applicable federal and state law, disclose to a family member or other relative, close person friend or any other person you identify, health information relevant to that person’s involvement to your care or payments related to your care.

National Security Activities for Protection of the President or Other Officials

• We may share your health information for national security activities for protection of the President or other officials if permitted by federal and state law.

Military Command Authorities

• We may share your health information with appropriate military command authorities if you are a member of the armed forces and sharing your information is permitted by federal and state law.

Health Information Exchange (HIE)

• We may use a Health information Exchange (HIE) to exchange electronic health information about you with other healthcare providers or entities that are not part of our healthcare system.
• Health information exchanged between providers or entities may be stored in their own systems and can be used for the purposes described in this Notice, to coordinate your care and as permitted by law.
• Unless prohibited by law, you are automatically opted in to such HIEs. If you wish to opt out, you must make a written request, which we will comply with unless disclosure is required by law. If you opt out of participating in these HIEs, your health information will no longer be provided to other health care entities through the HIE. However, your decision does not affect the health information that was exchanged prior to the time you opted out of participation.
• Note that certain sensitive information requires your consent prior to disclosure for these purposes, such as Part 2 Records, and will not be shared though the HIE unless we have obtained your consent as required by applicable law.

Minors

• A minor’s health information will be disclosed to their parents or legal guardians acting as personal representative, unless prohibited by law or in circumstances where the law permits us to withhold the information, such as to prevent harm to the minor or another person or in cases of suspected child abuse or neglect.

Breach Notification Purposes

• If for any reason there is an unsecured breach of your protected health information, we will use the contact information you have provided us with to notify you of the breach, as required by law. In addition, your protected health information may be disclosed as a part of the breach notification and reporting process.

Business Associates

• We may disclose your health information to Business Associates and/or Qualified Service Organizations contracted by us to perform services on our behalf, which may involve receipt, use or disclosure of your health information.
• All of our Business Associates must agree to (i) protect the privacy of your health information; (ii) use and disclose the health information only for the purposed for which Business Associate was engaged; (iii) if receiving SUD information, be bound by 42 CFR Part 2 and, if necessary, resist in judicial proceedings any efforts to obtain access to patient records except as permitted by law.
• We may also share your health information with a Business Associate who will remove information that identifies you so that the remaining information can be used or disclosed for purposed outside of this Notice.

SUBSTANCE USE DISORDER TREATMENT RECORDS

Centerstone offers substance use disorder (SUD) treatment programs and is required to comply with the federal Confidentiality of Substance Use Disorder Patient Records laws and regulations (42 CFR Part 2) that place strict limitations on how these records may be used or disclosed for individuals who are receiving any type of treatment related to substance use disorders.

Substance Use Disorder (SUD) is a condition where a person keeps using a drug or substance even though it’s causing serious problems in their life. These problems can include trouble controlling their use, issues at work or in relationships, using in dangerous situations, and physical effects like needing more of the substance to feel the same effect or having withdrawal symptoms when they stop. This definition does not include tobacco or caffeine use.

We will obtain your written consent to use and disclose your SUD records unless we are permitted to use and disclose SUD records without your written consent consistent with 42 CFR Part 2. The following categories describe the ways that we may use and disclose your SUD records without your written consent under 42 CFR Part 2.

 Medical Emergencies

• We may disclose your SUD records to medical personnel to the extent necessary to meet a bona fide medical emergency in which the your prior written consent cannot be obtained or in which we are closed and unable to provide services or obtain your prior written consent during a temporary state of emergency declared by a state or federal authority as the result of a natural or major disaster, until such time as we resume operations.
• We will obtain your authorization prior to disclosing your information for non-emergency treatment.

Food and Drug Administration (FDA)

• We may disclose your SUD records to medical personnel of the Food and Drug Administration (FDA) who assert a reason to believe that your health may be threatened by an error in the manufacturer, labeling, or sale of a product under the FDA jurisdiction, and that your SUD records will be used for the exclusive purpose of notifying you or your physicians of potential danger.

Research

• Under certain circumstances, we may use and disclose your SUD records without your consent for research purposes.
• Generally, we would first obtain your written consent; however, in certain circumstances, we may be permitted to use or disclose your SUD records for research purposes without your consent to the extent permitted by HIPAA, FDA and HHS regulations related to human subject research where a waiver of consent has been granted.

Management and Financial Audits and Program Evaluation

• Under certain circumstances we may use or disclose your SUD records for purposes of the performance of certain program financial and management audits and evaluations.
• For example, we may disclose your identifying information to any federal, state, or local government agency that provides financial assistance to the Part 2 program or is authorized by law to regulate the activities of Part 2 program.
• We may also use or disclose your identifying information to qualified personnel who are performing audit or evaluation functions on behalf of any person that provides financial assistance to the Part 2 program, which is a third-party payer or health plan covering you in your treatment, or which is a quality improvement organization (QIO), performing QIO review, the contractors, subcontractors, or legal representatives of such person or QIO, or an entity with direct administrative control over our program.

Fundraising

• Consistent with provisions elsewhere in this Notice, we may also use or disclose your

 Public Health

• We may use or disclose to a public health authority your SUD records for public health purposes. However, the contents of the information from the SUD records disclosed will be de-identified in accordance with the requirements of the HIPAA regulations, such that there will be no reasonable basis to believe that the information can be used to identify you.

Marketing Purposes

• Disclosures for marketing purposes which result in our receiving financial payment from a third party whose product or services is being marketed will require your written authorization. This does not include compensation that merely covers our cost of reminding you to take and refill your medication or otherwise communicate about a drug or biologic that is currently prescribed to you.
• However, we may use or disclose your PHI without your authorization to send you information about alternative medical treatments, our own programs or about health-related products and services that may be of interest to you, provided that we do not receive financial remuneration for making such communications. For example, we may use your PHI to assess your eligibility and propose newly available treatments.
• When we see you face-to-face, we may also use your PHI without your authorization to encourage you to maintain a healthy lifestyle and get recommended tests, suggest that you participate in a disease management program, provide you with promotional gifts of nominal value, or tell you about government sponsored health programs.

Sale of PHI

• For example, we cannot share your PHI in exchange for direct or indirect remuneration constituting a sale of PHI under HIPAA without your prior authorization.

WE MAY USE AND DISCLOSE YOUR SUD RECORDS WHEN YOU GIVE YOUR WRITTEN CONSENT SATISFYING THE REQUIREMENTS OF PART 2.

Designated person or entities

• We may use and disclose your SUD records in accordance with the consent to any person or category of persons identified or generally designated in the consent. For example, if you provide written consent naming your spouse or a healthcare provider, we will share your health information with them as outlined in your consent.

Single Consent for Treatment, Payment or Healthcare Operations

• We may also use and disclose your SUD records when the consent provided is a single consent for all future uses and disclosures for treatment, payment, and healthcare operations, as permitted by the HIPAA regulations, until such time you revoke such consent in writing.

Central Registry or Withdrawal Management Program

• We may disclose your SUD records to a central registry or to any withdrawal management or treatment program for the purposes of preventing multiple enrollments, with your written consent. For instance, if you consent to participating in a drug treatment program, we can disclose your information to the related program to coordinate care and avoid duplicate enrollment.

Criminal Justice System

• We may disclose information from your SUD records to those persons within the criminal justice system who have made your participation in the Part 2 program a condition of the disposition of any criminal proceeding against you.
• The written consent must state that it is revocable upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event. The time or occurrence upon which consent becomes revocable may be no later than the final disposition of the conditional release or other action in connection with which consent was given.
• For example, if you consent, we can inform a court-appointed officer about your treatment status as part of legal agreement or sentencing conditions.

PDMPs

• We may report any medication prescribed or dispensed by us to the applicable state prescription drug monitoring program if required by applicable state law.
• We will first obtain your consent to a disclosure of SUD records to a prescription drug monitoring program prior to reporting of such information.

 Civil, administrative, criminal, or legislative proceedings, subpoenas, and court orders

• Any Part 2 Record, or testimony relaying the content of such SUD records, shall not be used or disclosed in a civil, administrative, criminal, or legislative proceeding against you unless you provide specific written consent (separate from any other consent) or a court issues an appropriate order.
• Your SUD records will only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you, the Centerstone ACE or other holder of the Part 2 Record in accordance with Part 2.
• A court order authorizing use or disclosure of SUD records must be accompanied by a subpoena or other similar legal mandate compelling disclosure before the SUD records may be used or disclosed.

Exceptions

• 42 CFR Part 2 does not protect health information about a crime committed on our premises or against any of our personnel or about any threat to commit such crime.
• 42 CFR Part 2 also does not prohibit the disclosure of health information by us to report suspected child abuse or neglect under state law to appropriate state or local authorities.
• The restrictions on use and disclosure in 42 CFR Part 2 do not apply to communications of SUD records between or among personnel having a need for them in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of patients with substance use disorders if the communications are within the program (or with an entity that has direct administrative control over the program the communications between a part 2 program) and to communications of SUD records to a qualified service organization if needed by the qualified service organization to provide services to or on behalf of the Centerstone ACE (similar to provisions herein regarding Business Associates).

To the extent applicable state law is even more stringent than 42 CFR Part 2 on how we may use or disclose your health information, we will comply with the more stringent state law.

Psychotherapy/SUD Counseling Notes: Psychotherapy/SUD Counseling notes are defined as notes taken to analyze a conversation during a session that are maintained separate from your health record. We do not maintain these types of notes.

NOTICE OF REDISCLOSURE

PHI that is disclosed pursuant to this Notice may be subject to redisclosure by the recipient and no longer protected by HIPAA. Laws applicable to the recipient may limit their ability to use and disclose

the PHI received, such as if they are another covered entity subject to HIPAA or a program or entity subject to 42 CFR Part 2.

Please note that if SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI.

OUR RESPONSIBILITIES

 Privacy and Security: We are required by law to maintain the privacy and security of your protected health information.

 Breach Notification: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your health information. In no event will notification be more than 60 days from the date of the breach.

 Compliance: We must follow the duties and privacy practices described in this Notice and give you a copy of it.

 Revoking your Authorization: We will not use or share your health information other than as described here unless you tell us, in writing, that we may do so. If you tell us that we may, you have the right to change your mind at any time by telling us in writing that you have changed your mind. This will not apply to disclosures that have already occurred with your authorization.

For more information regarding your rights and our responsibilities please contact the Compliance & Privacy Officer for your service location or visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF THIS NOTICE

We may change the terms of this Notice, and the changes will apply to all information we have about you as well as any information we receive in the future. The new Notice will be available upon request, in our facilities, and on our web site: www.centerstone.org. Additionally, we will prominently display a copy of the current notice in common areas within Centerstone’s facilities. Each time you register at or are admitted to Centerstone for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

HOW TO MAKE A COMPLAINT IF YOU FEEL YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED

If you believe your privacy rights have been violated, you may file a complaint with Centerstone or with the Secretary of the Department of Health and Human Services. Centerstone will never ask you to waive your right to complain.

To file a complaint with Centerstone please contact the Compliance Office listed at the end of this Notice.

To file a complaint with the Secretary of the Department of Health and Human Services, by sending a letter to 200 Independence Avenue, S.W., Washington, D.

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT!

CONTACT INFORMATION

For questions and concerns regarding client privacy, your rights under the federal privacy standards, and our privacy practices please email: NPP.Questions@centerstone.org or call toll-free (855) 450-5770.

Language Assistance and Auxiliary Aids & Client/Patient Non-Discrimination Notice

Non-Discrimination Notice

Comprehensive Mental Health Services complies with applicable Federal civil rights laws and does not discriminate against clients/patients on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP). Comprehensive Mental Health Services does not exclude people or treat them less favorably because of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP).

Comprehensive Mental Health Services:

• Provides individuals with disabilities (including individuals’ companions with disabilities) reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:
  • Qualified interpreters, including American Sign Language
  • Written information in other formats (large print, audio, accessible electronic formats, other formats).
• Provides free language assistance services to individuals whose primary language is not English (including individuals’ companions with limited English proficiency), which may include:
  • Qualified interpreters
  • Electronic and written translated documents

If you need appropriate auxiliary aids and services or language assistance services, contact the Compliance and Integrity department at 855-450-5770 or LanguageServices@LiveBrightli.org.

If you need reasonable modifications, contact your provider and/or the Section 1557 Coordinator, Leah Barber at 855-450-5770 or BrightliCompliance@LiveBrightli.org.

If you believe that Comprehensive Mental Health Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, religion or any other characteristic protected by applicable federal, state or local laws, you can file a complaint/grievance by contacting the Section 1557 Coordinator, Leah Barber, via:

• Phone: 855-450-5770
• Email: BrightliCompliance@LiveBrightli.org
• Mail: Section 1557 Coordinator c/o Brightli Compliance and Integrity Department, 1111 S. Glenstone Ave, Springfield, MO 65804

You can file a grievance in person or by mail or email. If you need help filing a grievance, the Section 1557 Coordinator, Leah Barber, is available to help you.

You can also file a civil rights complaint with applicable state agencies and/or the U.S. Department of Health and Human Services, Office for Civil Rights:

• Electronically through the Office for Civil Rights Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
• Mail: U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. – 509F, Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This notice is available at Comprehensive Mental Health Service’s website: thecmhs.com.

Language Assistance and Auxiliary Aids and Services Available

• To receive prompt evaluation, care and treatment.
• To be informed of diagnosis and treatment (including potential risks and benefits of treatment) in terms that are understandable, and to participate in treatment planning to the fullest extent possible, including asking questions about any procedures used in treatment.
• To receive sufficient information to enable the client/patient to give or withdraw informed consent regarding service delivery, concurrent services and composition of service delivery team.
• To be provided with an interpreter and/or auxiliary aids, if necessary.
• To receive these services in the least restrictive environment.
• To receive these services in a clean and safe setting.
• To not be denied admission or services on the basis of race, color, national origin, age, disability, sex, religion, any other characteristic protected by applicable federal, state or local laws or inability to pay or whether payment for those services would be made under Medicare, Medicaid or Children’s Health Insurance Program (CHIP).
• To have confidentiality of information and records in accordance with federal and state law and regulation.
  • Federal laws and regulations do not protect any information related to suspected harm to self or others and suspected abuse or neglect from being reported under state law to appropriate state of local authorities.
• To be treated with dignity and addressed in a respectful, age appropriate manner.
• To receive humane care and treatment, free from abuse, neglect, corporal punishment and other mistreatment such as humiliation, retaliation, threats or exploitation, including financial exploitation.
• To receive medical care and treatment in accordance with acceptable standards of medical practice, if the program offers medical care and treatment.
• To consult with a private, licensed practitioner at one’s own expense.
• To have the same legal rights and responsibilities as any other citizen, unless otherwise prescribed by law.
• To be the subject of an experiment or research only with one’s informed, written consent, or the consent of an individual legally authorized to act, and to decide to withdraw at any time.
• To refuse hazardous treatment unless a person legally authorized to act on behalf of the client/patient has given Comprehensive Mental Health Services permission to proceed with treatment.
• To request and receive a second opinion before hazardous treatment, except in an emergency.
• To not participate in non-therapeutic labor.
• To file a complaint or grievance, without punishment or retaliation, and receive an impartial review if one believes that any of the rights listed above have been violated.
• To have access to records and information pertinent to the individual, in sufficient time to facilitate their decision making and determine who will have access to those records and information.
• To have access or be referred to legal entities for appropriate representation, self-help support services, and advocacy support services.

How Do You Ask for Change?

• Talk to your service provider and ask for what you want. You can request assistance from an advocate to help communicate the changes you want.
• Use the T.I.P.S. (Thoughts, Improvements, Problems and Solutions) Feedback Form to identify the changes you want. Give that form to your service provider or submit it directly online. If you need assistance in filling out the form, help will be provided to you.
• When you ask for a change, your service provider will try to find a way to make the changes you want. If this is not possible, they will explain why. If you are not satisfied with the answer you receive, you can file an appeal.
• If you are not satisfied with the response, you may appeal your request to the Regional or Departmental Executive Leadership team:
  • Email: cqi@livebrightli.org
  • Mail: Brightli c/o CQI 1111 S Glenstone Ave Springfield, MO 65807
• If you feel your rights have been violated and/or would like to file a formal complaint, contact the Compliance and Integrity department:
  • Phone: 855-450-5770
  • Email: BrightliCompliance@LiveBrightli.org

TIPS Feedback Form:

Centerstone Affiliated Covered
Entity Notice of Privacy Practices

This notice describes:

• How health, mental health and substance use disorder information about you may be used and disclosed.
• How you may get access to your health information.
• Your rights with respect to your health information.
• How to file a complaint concerning a violation of the privacy or security of your health information, or of your rights concerning your information.
• You have a right to a copy of this notice (in paper or electronic form) and to discuss it with the compliance office listed at the end of this notice if you have any questions.

Please review it carefully.

AFFILIATED ENTITIES COVERED BY THIS NOTICE

This Notice of Privacy Practices (“Notice”) covers an Affiliated Covered Entity (“ACE”). An ACE is a group of Covered Entities that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (HIPAA). Certain ACE members may also be considered a Substance Use Disorder (SUD) Treatment Program, which is governed by the Confidentiality of Substance Use Disorder Records regulations set forth in 42 CFR Part 2. These members have designated themselves as a single SUD Treatment Program for compliance with 42 CFR Part 2. When this Notice refers to “Centerstone ACE” and/or “Centerstone’: it is referring collectively to the Ccntcrstonc ACE. For a current list of Ccntcrstonc ACE members, please visit www.ccntcrstonc.org or contact the Compliance Office listed at the end of this notice.

Centerstone ACE is committed to protecting the privacy and security of your medical, mental heath and substance abuse information. We are required by law to maintain the privacy and security of your heath information, to provide you this notice and to comply with its terms. The privacy practices in this Notice apply to all staff, students, volunteers, contract staff and business associates and/or qualified service organizations.

Centerstone and certain affiliated organizations participate in one or more Organized Health Care Anangements (OHCA) as defined by the HIP AA Privacy Rule. An OHCA allows participating entities to share health information for joint quality improvement activities and other heath care operations. For a current list of OHCA participants please visit our website at www.centerstone.org or contact the Compliance Office listed at the end of this notice.

As part of these arrangements, your health information may be shared among OHCA participants or through a health information exchange only when necessary for treatment or health care operations. Health care operations may include activities such as quality assessment, clinical review, improving referral management, and enhancing care through technology (for example, geocoding your address to improve service delivery).

Your health information may include past, present, and future medical information, as permitted by law. All disclosures will comply with the HIPAA Privacy Rule and other applicable laws. You may revoke your consent in writing at any time; however, information already shared under your prior consent cannot be retracted. Upon request, you may receive a list of entities to which your information has been disclosed.

YOUR RIGHTS

When it comes to your health information, you have certain rights that apply to your records including substance use disorder (SUD) treatment records. This section explains your rights and some of our responsibilities to help you.

Review your record or get an electronic copy or paper copy of your medical records

• You can ask to see or get an electronic or paper copy of your health information we maintain about you. You may send your written request to the Compliance Office listed at the end of this Notice. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable cost-based fee.
• You may also request to review your medical record. You will be given access to your records for review along with your treatment provider
• We may provide a patient portal as one option for patients to electronically access their health information. If we have a patient portal, you may request access by contacting your health care provider. There is no fee for you to access health information through our patient portal.

Ask us to correct your medical record

• You may ask us to correct health information about you that you think is incomplete or incorrect. You may do this by submitting your request in writing to the Compliance Office listed at the end of this Notice. You must include a reason for the request.
• We may say “no” to your request, but we will tell you why in writing within 60 days, for example: The information was not created by us;
  • The information is not part of the information kept by or for Centerstone;
  • The information is not part of the information which you would be permitted to review and copy; or
  • The information in the record is accurate and complete.

Request confidential communications

• You may ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• To request confidential communications, you must make your request in writing to the Compliance Office listed at the end of this Notice.
• We will not ask you for the reason for your request.
• Your request must specify how or where you wish to be contacted.
• We will generally approve reasonable requests.

Ask us to limit what we use or share

• You may ask us not to use or share certain health information for treatment, payment or our operations.
• We are not required to agree with your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full and before the item or service is provided, you may ask us not to share that information with your insurer for the purpose of payment or our operations. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared your health information

• You may ask for a list (accounting) of the times we’ve shared your information for 6 years prior to the date you ask and why we share it.
• We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
• We will provide one (1) accounting a year free of charge but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of the privacy notice

• You may ask for, and we will promptly provide you with a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take action.

File a complaint if you feel your rights are violated

• You may file a complaint if you feel we have violated your rights by contacting us using the information on the last page of this Notice.
• You can file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington , D.C., calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you may 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, talk to us. Tell 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 friend, 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 go ahead and share your information if we believe it is in your best interest.
• We may also share information when needed to lessen a serious or imminent threat to health or safety.
• Centerstone does not create or maintain a facility directory.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes.
• Sale of your health information.
• Most sharing of psychotherapy notes, to the extent such exist.

In the case of fundraising:

• We may contact you for fundraising efforts, but you may tell us not to contact you again by contacting the Compliance Office listed at the end of this Notice.
• If you opt out of fundraising communications, it will not affect your care.

EXERCISING YOUR RIGHTS/ MAKING YOUR CHOICES

Any requests and/or exercise of your rights, as described in this Notice, may be made by providing written notice to the Compliance Office listed at the end of this Notice.

• To Treat You: If permitted by applicable state and federal law, we may use your health information and share it with professionals who are treating you.
• To Bill for Services: If permitted by applicable state and federal law, we will use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
• To Run Our Organization: If permitted by applicable state and federal law, we may use and share your health information to run Centerstone and improve the quality of your care; to respond to audits and investigation; for licensing purposes. Example: We use health information about you to manage your treatment and services; to evaluate our performance in providing services.

OTHER USES AND DISCLOSURES

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet any conditions in applicable law before we may share your information for these purposes. For more information, visit: www.hhs.gov /ocr/privacy/hipaa /understanding/consumers/index.html

Help with public health and safety issues

If permitted by applicable state and federal law, we may 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 someone’s health or safety as long as: The disclosure is made to someone able to help prevent the threat, and
  • Only under the conditions described by applicable state law.

Research

• If permitted by applicable state and federal law, we may use or share your information for health research, provided certain conditions are met.

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 wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• If permitted by applicable state and federal law, we may share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• If permitted by applicable state and federal law, we may share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

If permitted by applicable state and federal law, we may use or share health information about you:

• For workers’ compensation claims;
• For law enforcement purposes with a law enforcement official;
• With health oversight agencies for activities authorized bylaw;
• For special government functions, such as military and veterans authority, national security, and presidential protective services.

Respond to lawsuits and legal actions

• We may share health information about you in response to court or administrative orders as permitted by applicable federal and state law.

Communication regarding inmates in correctional facilities

If you are an inmate in a correctional facility or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official if permitted by applicable federal and state law and the release of the information is necessary:

• For the correctional facility or institution to provide you with health care; or
• To protect your health or safety or the health or safety of others; or
• For the safety and security of the correctional facility or institution.

Communications with family

• If you receive services in an inpatient or residential setting, we may, as allowed by applicable federal and state law, disclose to a family member or other relative, close person friend or any other person you identify, health information relevant to that person’s involvement to your care or payments related to your care.

National Security Activities for Protection of the President or Other Officials

• We may share your health information for national security activities for protection of the President or other officials if permitted by federal and state law.

Military Command Authorities

• We may share your health information with appropriate military command authorities if you are a member of the armed forces and sharing your information is permitted by federal and state law.

Health Information Exchange (HIE)

• We may use a Health information Exchange (HIE) to exchange electronic health information about you with other healthcare providers or entities that are not part of our healthcare system.
• Health information exchanged between providers or entities may be stored in their own systems and can be used for the purposes described in this Notice, to coordinate your care and as permitted by law.
• Unless prohibited by law, you are automatically opted in to such HIEs. If you wish to opt out, you must make a written request, which we will comply with unless disclosure is required by law. If you opt out of participating in these HIEs, your health information will no longer be provided to other health care entities through the HIE. However, your decision does not affect the health information that was exchanged prior to the time you opted out of participation.
• Note that certain sensitive information requires your consent prior to disclosure for these purposes, such as Part 2 Records, and will not be shared though the HIE unless we have obtained your consent as required by applicable law.

Minors

• A minor’s health information will be disclosed to their parents or legal guardians acting as personal representative, unless prohibited by law or in circumstances where the law permits us to withhold the information, such as to prevent harm to the minor or another person or in cases of suspected child abuse or neglect.

Breach Notification Purposes

• If for any reason there is an unsecured breach of your protected health information, we will use the contact information you have provided us with to notify you of the breach, as required by law. In addition, your protected health information may be disclosed as a part of the breach notification and reporting process.

Business Associates

• We may disclose your health information to Business Associates and/or Qualified Service Organizations contracted by us to perform services on our behalf, which may involve receipt, use or disclosure of your health information.
• All of our Business Associates must agree to (i) protect the privacy of your health information; (ii) use and disclose the health information only for the purposed for which Business Associate was engaged; (iii) if receiving SUD information, be bound by 42 CFR Part 2 and, if necessary, resist in judicial proceedings any efforts to obtain access to patient records except as permitted by law.
• We may also share your health information with a Business Associate who will remove information that identifies you so that the remaining information can be used or disclosed for purposed outside of this Notice.

SUBSTANCE USE DISORDER TREATMENT RECORDS

Centerstone offers substance use disorder (SUD) treatment programs and is required to comply with the federal Confidentiality of Substance Use Disorder Patient Records laws and regulations (42 CFR Part 2) that place strict limitations on how these records may be used or disclosed for individuals who are receiving any type of treatment related to substance use disorders.

Substance Use Disorder (SUD) is a condition where a person keeps using a drug or substance even though it’s causing serious problems in their life. These problems can include trouble controlling their use, issues at work or in relationships, using in dangerous situations, and physical effects like needing more of the substance to feel the same effect or having withdrawal symptoms when they stop. This definition does not include tobacco or caffeine use.

We will obtain your written consent to use and disclose your SUD records unless we are permitted to use and disclose SUD records without your written consent consistent with 42 CFR Part 2. The following categories describe the ways that we may use and disclose your SUD records without your written consent under 42 CFR Part 2.

 Medical Emergencies

• We may disclose your SUD records to medical personnel to the extent necessary to meet a bona fide medical emergency in which the your prior written consent cannot be obtained or in which we are closed and unable to provide services or obtain your prior written consent during a temporary state of emergency declared by a state or federal authority as the result of a natural or major disaster, until such time as we resume operations.
• We will obtain your authorization prior to disclosing your information for non-emergency treatment.

Food and Drug Administration (FDA)

• We may disclose your SUD records to medical personnel of the Food and Drug Administration (FDA) who assert a reason to believe that your health may be threatened by an error in the manufacturer, labeling, or sale of a product under the FDA jurisdiction, and that your SUD records will be used for the exclusive purpose of notifying you or your physicians of potential danger.

Research

• Under certain circumstances, we may use and disclose your SUD records without your consent for research purposes.
• Generally, we would first obtain your written consent; however, in certain circumstances, we may be permitted to use or disclose your SUD records for research purposes without your consent to the extent permitted by HIPAA, FDA and HHS regulations related to human subject research where a waiver of consent has been granted.

Management and Financial Audits and Program Evaluation

• Under certain circumstances we may use or disclose your SUD records for purposes of the performance of certain program financial and management audits and evaluations.
• For example, we may disclose your identifying information to any federal, state, or local government agency that provides financial assistance to the Part 2 program or is authorized by law to regulate the activities of Part 2 program.
• We may also use or disclose your identifying information to qualified personnel who are performing audit or evaluation functions on behalf of any person that provides financial assistance to the Part 2 program, which is a third-party payer or health plan covering you in your treatment, or which is a quality improvement organization (QIO), performing QIO review, the contractors, subcontractors, or legal representatives of such person or QIO, or an entity with direct administrative control over our program.

Fundraising

• Consistent with provisions elsewhere in this Notice, we may also use or disclose your

 Public Health

• We may use or disclose to a public health authority your SUD records for public health purposes. However, the contents of the information from the SUD records disclosed will be de-identified in accordance with the requirements of the HIPAA regulations, such that there will be no reasonable basis to believe that the information can be used to identify you.

Marketing Purposes

• Disclosures for marketing purposes which result in our receiving financial payment from a third party whose product or services is being marketed will require your written authorization. This does not include compensation that merely covers our cost of reminding you to take and refill your medication or otherwise communicate about a drug or biologic that is currently prescribed to you.
• However, we may use or disclose your PHI without your authorization to send you information about alternative medical treatments, our own programs or about health-related products and services that may be of interest to you, provided that we do not receive financial remuneration for making such communications. For example, we may use your PHI to assess your eligibility and propose newly available treatments.
• When we see you face-to-face, we may also use your PHI without your authorization to encourage you to maintain a healthy lifestyle and get recommended tests, suggest that you participate in a disease management program, provide you with promotional gifts of nominal value, or tell you about government sponsored health programs.

Sale of PHI

• For example, we cannot share your PHI in exchange for direct or indirect remuneration constituting a sale of PHI under HIPAA without your prior authorization.

WE MAY USE AND DISCLOSE YOUR SUD RECORDS WHEN YOU GIVE YOUR WRITTEN CONSENT SATISFYING THE REQUIREMENTS OF PART 2.

Designated person or entities

• We may use and disclose your SUD records in accordance with the consent to any person or category of persons identified or generally designated in the consent. For example, if you provide written consent naming your spouse or a healthcare provider, we will share your health information with them as outlined in your consent.

 Single Consent for Treatment, Payment or Healthcare Operations

• We may also use and disclose your SUD records when the consent provided is a single consent for all future uses and disclosures for treatment, payment, and healthcare operations, as permitted by the HIPAA regulations, until such time you revoke such consent in writing.

Central Registry or Withdrawal Management Program

• We may disclose your SUD records to a central registry or to any withdrawal management or treatment program for the purposes of preventing multiple enrollments, with your written consent. For instance, if you consent to participating in a drug treatment program, we can disclose your information to the related program to coordinate care and avoid duplicate enrollment.

Criminal Justice System

• We may disclose information from your SUD records to those persons within the criminal justice system who have made your participation in the Part 2 program a condition of the disposition of any criminal proceeding against you.
• The written consent must state that it is revocable upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event. The time or occurrence upon which consent becomes revocable may be no later than the final disposition of the conditional release or other action in connection with which consent was given.
• For example, if you consent, we can inform a court-appointed officer about your treatment status as part of legal agreement or sentencing conditions.

PDMPs

• We may report any medication prescribed or dispensed by us to the applicable state prescription drug monitoring program if required by applicable state law.
• We will first obtain your consent to a disclosure of SUD records to a prescription drug monitoring program prior to reporting of such information.

Civil, administrative, criminal, or legislative proceedings, subpoenas, and court orders

• Any Part 2 Record, or testimony relaying the content of such SUD records, shall not be used or disclosed in a civil, administrative, criminal, or legislative proceeding against you unless you provide specific written consent (separate from any other consent) or a court issues an appropriate order.
• Your SUD records will only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you, the Centerstone ACE or other holder of the Part 2 Record in accordance with Part 2.
• A court order authorizing use or disclosure of SUD records must be accompanied by a subpoena or other similar legal mandate compelling disclosure before the SUD records may be used or disclosed.

Exceptions

• 42 CFR Part 2 does not protect health information about a crime committed on our premises or against any of our personnel or about any threat to commit such crime.
• 42 CFR Part 2 also does not prohibit the disclosure of health information by us to report suspected child abuse or neglect under state law to appropriate state or local authorities.
• The restrictions on use and disclosure in 42 CFR Part 2 do not apply to communications of SUD records between or among personnel having a need for them in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of patients with substance use disorders if the communications are within the program (or with an entity that has direct administrative control over the program the communications between a part 2 program) and to communications of SUD records to a qualified service organization if needed by the qualified service organization to provide services to or on behalf of the Centerstone ACE (similar to provisions herein regarding Business Associates).

To the extent applicable state law is even more stringent than 42 CFR Part 2 on how we may use or disclose your health information, we will comply with the more stringent state law.

Psychotherapy/SUD Counseling Notes: Psychotherapy/SUD Counseling notes are defined as notes taken to analyze a conversation during a session that are maintained separate from your health record. We do not maintain these types of notes.

NOTICE OF REDISCLOSURE

PHI that is disclosed pursuant to this Notice may be subject to redisclosure by the recipient and no longer protected by HIPAA. Laws applicable to the recipient may limit their ability to use and disclose the PHI received, such as if they are another covered entity subject to HIPAA or a program or entity subject to 42 CFR Part 2.

Please note that if SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI.

OUR RESPONSIBILITIES

Privacy and Security: We are required by law to maintain the privacy and security of your protected health information.

Breach Notification: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your health information. In no event will notification be more than 60 days from the date of the breach.

Compliance: We must follow the duties and privacy practices described in this Notice and give you a copy of it.

Revoking your Authorization: We will not use or share your health information other than as described here unless you tell us, in writing, that we may do so. If you tell us that we may, you have the right to change your mind at any time by telling us in writing that you have changed your mind. This will not apply to disclosures that have already occurred with your authorization.

For more information regarding your rights and our responsibilities please contact the Compliance & Privacy Officer for your service location or visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF THIS NOTICE

We may change the terms of this Notice, and the changes will apply to all information we have about you as well as any information we receive in the future. The new Notice will be available upon request, in our facilities, and on our web site: www.centerstone.org. Additionally, we will prominently display a copy of the current notice in common areas within Centerstone’s facilities. Each time you register at or are admitted to Centerstone for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

HOW TO MAKE A COMPLAINT IF YOU FEEL YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED

If you believe your privacy rights have been violated, you may file a complaint with Centerstone or with the Secretary of the Department of Health and Human Services. Centerstone will never ask you to waive your right to complain.

To file a complaint with Centerstone please contact the Compliance Office listed at the end of this Notice.

To file a complaint with the Secretary of the Department of Health and Human Services, by sending a letter to 200 Independence Avenue, S.W., Washington, D.

 YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT!

CONTACT INFORMATION

For questions and concerns regarding client privacy, your rights under the federal privacy standards, and our privacy practices please email: NPP.Questions@centerstone.org or call toll-free (855) 450-5770.

Safety

Centerstone’s commitment to safety prompted us to create a component Patient Safety Organization (PSO) which focuses on improving patient safety and the quality of health care delivery. Centerstone’s PSO has been recently recognized by the Agency for Healthcare Research and Quality (AHRQ), the lead Federal agency charged with improving the safety and quality of healthcare.

Centerstone also has many policies and procedures in place that offer guidance for the protection of personal health information (PHI), emergency procedures, infection control, physical safety and accident prevention as well as incident reporting. These guidelines provide best practices for Centerstone staff so they can keep themselves, patients and our visitors safe.

Quality

We know that quality care results in improved outcomes for our patients, and we strive to ensure everyone receives the very best quality care when they come to Centerstone. We work hard to meet stringent quality standards and have demonstrated our commitment to quality through long-standing accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) and The Joint Commission. These organizations set the standard for healthcare providers to monitor quality, improve processes, measure outcomes and set expectations for exceptional service delivery.

Compliance

Compliance is another layer of protection for Centerstone patients and staff. We’ve created a comprehensive compliance program which helps prevent accidents, violations and misconduct before they occur. Our staff is required to report instances of fraud, waste and abuse to their supervisor, Centerstone management or our Compliance Officer. If you suspect fraud, waste or abuse, you can reach Centerstone’s confidential compliance hotline by calling 833-222-4126 or visiting this website.

For more information on Centerstone privacy, safety, or compliance topics, please review the resources below:

• Patient Privacy at Centerstone
• Notice of Privacy Practices (English)
• Notice of Privacy Practices (Spanish)
• Centerstone Behavioral Hospital & Addiction Center Pricing
• Report Compliance Issues