Form
HPS-400

State of Montana
Department of Public Health and
Human Services
NOTICE OF USE OF PROTECTED HEALTH INFORMATION
MONTANA CHEMICAL DEPENDENCY CENTER

Effective Date April 14, 2003

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

You are applying for government programs that provide money or services. Before we can review your Application, we ask that you provide some personal information.

The laws say that:
1.   we must keep your Protected Health Information ("PHI") from others who do not need to know it; and
2.    you can tell us if there is some PHI you do not wish to be shared. However, in some cases, we may not be able to agree to your request.

Unless you tell us differently on your Application, we may share your Application information with other programs that may be able to help you. Some are programs for children, people with disabilities, and people who need financial help. If one of these programs can help you, they will contact you.

Healthcare providers who treat you may use your PHI. This may cover healthcare you have had in the past or may have in the future. We may also use your PHI to contact you about appointment reminders or to tell you about treatment alternatives.

We only share the minimum necessary PHI that is needed at the time by that provider or agency.

Your healthcare provider sends a claim to an insurance company or to a government program for payment. That claim contains all the information about the services you were provided.

Claims that are sent to us are reviewed to assure that you receive the quality health care every client deserves and that all laws governing medical care are being followed.

You are allowed to see your PHI unless it is the private notes taken a mental health provider, it is part of a legal case, or if your healthcare provider decides it would be harmful for you to see the information. Most of the time you can receive a copy if requested. You may be charged a small amount for the copying costs.

If you think some of the information is wrong, you may request, in writing, that it be changed or new information be added. You may ask that the changes be sent to others who have received your PHI. You can request and receive a list showing where your medical information has been sent, unless it was sent as part of your provider's care, to assure that you received quality care or to make sure the laws are being followed

You will be asked to sign a separate form, the Authorization for the Use and Disclosure of Health Information, allowing your PHI to be sent to another location. This would be used if your healthcare provider provides it to another location or if you request that we send it to another individual or healthcare provider for you.

The form gives the name and address that we are to send your PHI and the information you wish to be provided.

Your authorization is good for 6 months or until the date you put on the form (not more than 30 months). You can cancel or limit the amount of PHI sent at any time by written notification. [You may be charged a small amount for the copying costs. ]

Note: If you are under the age of 18, your parents or guardians will receive your PHI, unless, by law, you are able to consent for your own healthcare. If you are, then it will not be shared with them unless you sign an Authorization form.

We adhere to laws that provide specific instances when medical information must be shared, even if you do not sign an Authorization form. We always report:
1. contagious diseases;
2. reactions and problems with medicines;
3. to the police when required by law or when the courts so order;
4. to the government for audits and reviews of our programs;
5. to a provider or insurance company to verify your enrollment in one of our programs;
6. to Workers' Compensation for work related injuries;
7. birth, death and immunization information; and
8. to the federal government if required to investigate any matter pertaining to the protection our country, the President or other government workers.

This Notice is yours. If the information changes, you will be provided a copy of the updated Notice. If you have questions concerning this Notice, please ask the individual providing it. If that individual cannot answer your questions, call the Department of Public Health and Human Services ("DPHHS") Privacy Officer at (800) 645-8408.

You can also complain to the federal government Secretary of Health and Human Services by writing 200 Independence Ave. SW, Washington, DC 20201. This must be done within 180 days from the date you believe your privacy was violated. You can also complain to the Office for Civil Rights by calling (866) 627-7748.

Your Medicaid benefits will not be affected by a complaint made to the DPHHS Privacy Officer or to the Secretary of Health and Human Services.

I have been given a copy of this Notice and have been given the opportunity to ask questions concerning how my Protected Health Information will be used. I know that I can contact the DPHHS Privacy Officer at (800) 645-8408 if I have further concerns.

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