Advance Behavioral Health Services

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

Your Choices

You have some choices in the way that we use and share information as we:

Our Uses and Disclosures

We may use and share your information as we:

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights
and some of our responsibilities to help you

Get an electronic or paper copy of your medical record

Ask us to correct your medical record

Request confidential communications

Ask us to limit what we use or share

Get a list of those with whom we’ve shared information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you feel your rights are violated

Your Choices

For certain health information, you can 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:

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 your
information when needed to lessen a serious and imminent threat to health or safety.

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

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

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

Run our organization

Bill for your services

How else can we use or share your health information?

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 have to meet many conditions in the law before
we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

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

Respond to lawsuits and legal actions

For more information see:  www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about
you. The new notice will be available upon request, in our office, and on our web site.