Client Rights, Responsibilities, and Privacy Notice

PATHWAYS BEHAVIORAL SERVICES CONSUMER RESPONSIBILITIES

Responsibility to Keep Appointments

• Be prompt. Sessions are usually 45-50 minutes and billed accordingly.
• Decide with your counselor on the frequency of appointments
• Call 24 hours ahead to cancel

Responsibility To Be An Active Participant in Therapy

• Be open and honest about your situation and feelings
• With the help of your counselor, set goals and actions steps
• Practice new behaviors between sessions
• Follow your treatment plan
• Take medications regularly, if prescribed.
• Notify your counselor of any deterioration of thoughts about hurting yourself or others.
• Ask questions if you don’t understand.
• If you disagree with your counselor or you are not satisfied with treatment, say so.

Responsibility to Treat The Staff With Courtesy and Respect

• Respect the boundaries set by the counselor in your relationship
• Do not call your counselor at his/her home
• Express any anger without threats or abusive language

Responsibility to Pay Fees

• Provide current and accurate insurance information and inform the business office of any changes.
• Check with your insurance company to see whether services are covered or if there are any limitations on mental health or substance abuse services.
• Preauthorizes services with your insurance company
• Pay whatever is not covered by insurance at each visit
• Ask questions or tell us if you think we have made a mistake on your bill.

PATHWAYS BEHAVIORAL SERVICES CONSUMER RIGHTS

As a client served at Pathways Behavioral Services, you have specific rights. The purpose of this form is to inform you of your rights as our client.

I. Right to Voluntary Services

If you are a legal adult (18 years old in this state), you have the right to request voluntary services. You have a right to

• Have a staff person assigned specifically to work with you in resolving your problems and ensuring that your service is properly provided
• A personal, individualized assessment of your needs
• An Individualized service plan, which will be reviewed regularly, developed with your input, and implemented with your consent
• Services beginning within a reasonable time and ending when they are no longer needed or effective
• Services even when you are unable (not unwilling) to pay (ability to pay is determined by certain standard criteria set by the county in which you reside.)
• Another option regarding services provided (However, seeing someone outside of this setting is done at your own expense)
• Referrals to other competent professionals and sources of help as indicated by your service plane
• Terminate services if your circumstances require it or you feel it is in your best interest, unless doing so puts you or others in grave danger
• Resume service following termination

II. Right to Refuse Services

You have a right to

• Refuse any form or service or treatment unless it has been ordered by the court or in emergency situations when necessary to prevent harm to yourself and others (if you must receive services not by your own choice, you have the right to a lawyer, a court hearing, and an appeal of the decision to a higher court. If you cannot afford a lawyer, the court will appoint one for you.)
• Refuse service with your primary clinician and request another practitioner in this setting or a referral to another setting
• Be informed that without services, your situation may get worse
• Refuse to be filmed or audio taped without your written permission
• Refuse to take part in research studies without your written permission

III. Right to Confidentiality/Privacy

(See Notice of Privacy Practices)

IV. Right to Human Mental and Physical Environment

You have a right to

• Courtesy, respect, and professionalism from everyone involved in your service in this setting
• Facilities that are comfortable, safe, promote dignity, ensure privacy, and contribute to positive outcomes of your service

V. Right to Information

You have the right to verbal and written information about

• Your rights, role, and responsibilities as a client in this setting
• Your primary clinician’s rights, role, and responsibilities in this setting
• What you can expect during your service appointments, costs, handling of emergencies, and other practices and procedures of this setting as they affect your
• Any rights that are taken away and your right to a review of this action by requesting a Grievance Procedure
• Your primary clinician’s credentials and professional code of ethics
• Means to contact your primary clinician in both emergency and non-emergency situations
• The name of and means to contact your primary clinician’s supervisor
• Procedures for reviewing your clinical records (see Notice of Privacy Practices)

VI. Right Pertaining to Medication

You have a right to

• The administration of medication only under the written order of a physician
• A complete explanation in easy to understand language of the purpose of any medication, possible side effects, and possible results of long-term use
• Full consideration of your opinions and reactions to the medications
• A regular review of your medication for the purpose of adjustments, as a check for possible side effects, and for possible reduction or elimination
• Have accurate records kept noting your medication history, including any adverse reactions or drug allergies
• Have medication prescribed for you only when necessary

V. Right to a Grievance Procedure

Any client or legal representative of a client may file a grievance as a formal notice of dissatisfaction regarding the operation of this service and the actions or omissions of staff. If you wish to file a formal complaint, ask any staff member in this setting for the handout, “How to File a Complaint in This Setting.” The state regulatory board or the practitioner’s professional association also processes grievances. Information about how to contact theses organizations can be provided.

PATHWAYS BEHAVIORAL SERVICES Notice of Privacy Practices

I. This notice describes how we may use and disclose medical information and how to access this information. Please review it carefully.

II. Pathways Behavioral Services has a legal duty to safeguard Protected Health Information (PHI).

We are required to protect the privacy of health information. This information is called “protected health information,” or “PHI” for short, and it includes information that can be used to identify past, present, or futures health or condition, the provision of health care, or the payment of this health care. We are providing this notice to individuals receiving treatment, as well as business associates and other covered entities that explain how, when, and why we use and disclose PHI. With some exceptions, we may not use or disclose any more PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice.

However, Pathways Behavioral Services reserves the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptly change this notice and post a new notice in our waiting room. You can also request a copy of this notice from the contact person listed in Section VI below at any time.

III. How we may use and disclose Protected Health Information.

Pathways Behavioral Services uses and discloses health information for many different reasons. Below, we describe the different categories of our uses and disclosures and give some examples in each category.

A. We may use and disclose PHI for the following reasons with written consent. Once Pathways Behavioral Services’ consent form is signed, we may use and disclose PHI to:

1. Provide treatment

• The therapist providing treatment may seek clinical supervision regarding treatment from the clinical coordinator or psychiatrist.
• To communicate with the pharmacy of your choice regarding prescriptions or medical laboratory regarding lab tests and results.

2. For health care operations within Pathways behavioral Services

• The Center’s support staff will have access to PHI in order to perform necessary clerical duties
• The Center’s support staff may call to remind individuals receiving treatment of appointments or leave messages and ask for a return call.
• The Center’s administrative staff may use your PHI to do staff performance reviews or quality assurance activities
• To send you information regarding Center fund raising activities

3. To obtain payment for treatment

• The Center’s billing office may submit a claim form that contains the name of individual receiving treatment, address, social security number, diagnoses, dates of service and procedures performed in our office to the individual’s insurance company or third party payer. We may also respond to your third party payer, HMO, or insurance company’s request for information needed to determined eligibility, authorize treatment and manage your care. In these cases, the minimum necessary PHI will be provided.

B. Pathways Behavioral Services may use or disclose PHI for other purposes, without your consent or authorization in the following situations.

1. If the law requires us to disclose information to government authorities.

• In the interest of public health and safety (life-threatening situations)
• In response to a court order
• To report suspected child abuse or dependent adult abuse
• For national security purposes or intelligence operations
• Health oversight activities
• Location or identification of certain individuals by law enforcement
• Correctional institutions for the purpose of treatment or safety
• Compliance with laws related to workers compensation
• Specially authorized research

C. All other uses and disclosures require prior written authorization. This authorization is very specific to recipient and content and is time limited. It is voluntary in nature and can be revoked in writing to stop any further uses and disclosures.

D. Iowa law requires additional and separate prior written authorization to disclose any substance abuse and HIV information. Iowa law also prohibits multiple agency/recipient authorizations.

IV. Rights regarding PHI

Individuals receiving treatment at Pathways Behavioral Services have the following rights regarding PHI.

A. The right to request limits on uses and disclosures of PHI.
You have the right to ask that Pathways Behavioral Services limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosure that we are legally requires or allowed to make. Pathways Behavioral Services will not re-release PHI receive from other agencies or sources without be so specified on the written authorization. Substance abuse and HIV information will not be released without separate written authorization according to Iowa law.

B. The right to choose how we send PHI to you.
You may request that you receive confidential communication of PHI. You have the right to ask that we send information to you at an alternate address or by alternate means. Your request must be in writing and we must agree to your request so long as we can easily provided it in the format you requested.

C. The right to see and get copies of PHI.
In most cases, you have the right to look at or get copies of your PHI that we have. You will be asked to sign a written authorization to release information to yourself. You may be charged for copying and time to prepare summaries. If Pathways Behavioral Services does not have your PHI but know who does, we will tell you how to get it. If a request is made for PHI, we will respond to you within 30 days after receiving your written request. If certain situations, we may deny your request. If we do, we will tell you, in writing, our reason for the denial and explain your right to have the denial reviewed.

D. The right to request changes to your PHI.
If, after review of your PHI, you do not agree with the content, you may request that it be changed. Your request must be in writing and contain reasons to support a change. We will respond to your request in 60 days in writing, either granting or denying the requested changes. If your request is denied, you will receive the reasons in writing and be given the opportunity to have a written statement of disagreement incorporated into the PHI. Any further disclosures will include with the changes, or all of the documentation regarding the requested change.

E. The right to get a list of the disclosure we have made.
You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for payment or health care operations. The list will not include uses and disclosures made for national security purposes, to corrections, or law enforcement personnel, or before April 14, 2003

F. The right to request a paper copy of this notice.
The law requires that the Center provide notice of its legal duties and privacy practices, to abide by the terms of this notice and to provide individuals with notice revisions.

V. How to complain about our privacy practices.

If you think Pathways Behavioral Services may have violated your privacy rights, or you disagree with a decision we made abut access to your PHI, you may file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201. We will take no retaliatory action against you if you file a complaint about our privacy practices.

VI. Person to contact for information about this notice or to complain about our privacy practices.

If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact:

Pathways Behavioral Services

3362 University Avenue

Waterloo, Iowa 50701

319-235-6571

VII. Effective date of this notice is April 14, 2003, updated March 2016.