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

Grace & Mercy Community Service may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

• • "PHI" refers to information in your health record that could identify you.
• Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example would be consulting with another health care provider, such as a family physician.
• • Payment is when we obtain reimbursement for your healthcare, such as disclosing PHI to your health insurer to determine eligibility or coverage.
• • Health Care Operations are activities that relate to the performance and operation of the Young Adult Institute, such as quality assessment, audits, administrative services, and case management.
• • "Use" applies only to activities within the clinic such as sharing, employing, applying, utilizing, examining, and analyzing information.
• • "Disclosure" applies to activities outside of the clinic, such as releasing or transferring information to other parties.
• • "Authorization" is your written permission to disclose confidential mental health information, which must be on a specific legally required form.

GMCS may use or disclose PHI without your consent or authorization in the following circumstances:

• • Child Abuse - If there is reason to believe that a child has been subjected to abuse or neglect, we must report this belief to the appropriate authorities.
• • Adult and Domestic Abuse - GMCS may disclose protected health information regarding you if there is reasonable belief that you are a victim of abuse, neglect, self-neglect, or exploitation.
• • Health Oversight Activities - If GMCS receives a subpoena from the Maryland Board of Examiners of Physicians, Psychologists, Social Workers, Professional Counselors, or any other Mental Health Board because they are investigating the Clinic or any staff member, we must disclose any PHI requested by the Board.
• • Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and GMCS will not release information without your written authorization or a court order. The privilege does not apply when you are being evaluated or a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• • Serious Threat to Health or Safety - If you communicate a specific threat of imminent harm against another individual or if any GMCS staff member believes that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If GMCS staff believes that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.

• • Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information. However, GMCS is not required to agree to a restriction you request.
• • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are being seen at the Clinic. At your request, we will send your bills or other information to another address.)
• • Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. GMCS may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. You have the right to inspect or obtain a copy (or both) of Psychotherapy Notes unless we believe the disclosure of the record will be injurious to your health. On your request, your mental health provider will discuss with you the details of the request and denial process for both PHI and Psychotherapy Notes.
• • Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. GMCS may deny your request. At your request, a staff member will discuss with you the details of the amendment process.
• • Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI. At your request, a staff member will discuss the details of the accounting process with you.
• • Right to a Paper Copy - You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.

• • GMCS is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
• • We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
• • If we revise our policies and procedures, we will inform you verbally and/or in writing during the session following the revision.

If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact the Clinical Director at the above number.

If you believe that your privacy rights have been violated and wish to file a complaint with the clinic, you may send your written complaint to the above address.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. GMCS will not retaliate against you for exercising your right to file a complaint.

This notice will go into effect on May 1, 2020

GMCS reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice either verbally and/or in writing by, at the latest, during the session following the time the revision.

I have received a copy of this notice.