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Statement of Privacy Practices

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.

I.
  Cherokee Health Systems (called CHS hereafter in this statement) has always been very careful to protect the privacy of our clients' medical information. We respect your right to privacy and have always handled your personal health information entrusted to us with the utmost care. We hope that this statement of our privacy practices answers any questions or concerns that you might have about the privacy of your personal health information. Please ask us about anything you don't understand.

II.
  CHS, as all medical, behavioral and dental providers, is required by law to maintain the privacy of protected health information. We are also required by law to give you this statement and to operate by the practices as declared in this statement. The law requires us to give you this notice in advance of your first service whenever possible. But it also allows us to collect information via phone or other means ahead of time to expedite (speed up) our service to you and it allows us to treat you immediately in an emergency as long as we make a good faith effort to present you with the statement as soon as possible, which we will. We are required by law to prominently post this notice and any later revisions in all of our places of service. If you do not see this notice posted, please ask any staff person to point it out to you.

III.
  This notice is effective as of April 14, 2003. We may in the future find that it is necessary to change our practices and reserve the right to do so without notice. Any change to our practices will be highlighted and dated on the posted statement of our practices at all of our service locations by the time any changes go into effect and we will begin distributing revised statements by the date that any changes take effect. We encourage you to check our posted practices each time you visit. If we do find it necessary to change our practices over time we will not segregate (set apart or separate) our records according to the notice in effect at the time the entries into the records were created. We specifically reserve the right to not segregate our records in this notice. You are entitled to a copy of our privacy practices and any revisions at any time so please ask any staff person.

IV.
  The law further requires that we must make a good faith effort to obtain your written acknowledgment of receipt of this notice. That is why we are asking you (or your personal representative, for example, a parent of a child) to sign saying that we have given you this notice. If you do not sign this acknowledgement, the staff person who presented it to you will sign a statement saying that they gave it to you for our records. If you have any questions at any time about this statement or anything in it, please ask any staff person. If they do not answer your questions or address your concerns to your satisfaction please call William Berez, Ph.D., our Privacy Officer at (423) 714-2200 and press 8.

V.
  Your medical records are maintained here in a secure location, available only to those who need access to them and then only to the minimum necessary extent to accomplish their job to help in your treatment, pursuit of payment or success of our healthcare operations. If maintained or shared electronically, reasonable and appropriate security measures will be in place to protect the privacy of your information. All staff is trained in the methods of protection of your privacy and all staff has agreed in writing to abide by the practices as set forth in this notice.

VI.  

The law allows us to use your personal health information for the purposes of treatment, payment and healthcare operations. What this means is that while protecting the privacy of your information, releasing only the minimum necessary information to accomplish our purpose, in order to provide you the best treatment possible we must share your information among our professional staff and others.

A.

Disclosures For Treatment

1. For example, we are an integrated care company; that means that if you are a medical patient, your Primary Care Provider may think it is in your best interest to share your information with one of our "Behavioral Medical Consultants", a specially trained clinician who may be able to help you and your Primary Care Provider in the course of your treatment. If you are a Behavioral patient, our clinician may see the advantage to you of involving a primary care provider in your treatment. In either of these cases, there will be some sharing of your information among our professional staff to maximize the benefits of your treatment possibilities at CHS. Also, nurses and other clinical staff will have access to your records to the extent that it is necessary to assist the clinician in your care. And because many of our patients choose to visit more than one of our locations your record will be used by staff at all locations that you visit for the purpose of your treatment.

2. Another illustration is that if your Primary Care Provider finds it necessary to refer you to a Specialty Provider (say a cardiologist, for example), the part of your record that is pertinent to the treatment of your condition will be forwarded to the Specialty Provider in advance of your visit. After that visit, the Specialty Provider's records on your visit(s) to them will be in turn sent back to us to help us coordinate treatment. Some times a Specialty Provider must have access to your record in order to decide whether to accept the referral or not. They may then decide to accept the referral or not, but must be able to review your records in advance.

3. If you are a Behavioral patient, who sees one of our mental health clinicians for assessment and ongoing treatment your rights are different under state law in Tennessee. While your information can be shared internally as necessary for your treatment, any release of your record to an outside entity other than your insurance company or other payor using the minimum necessary standard (if you have signed an authorization), or under certain circumstances to a governmental agency (including but not limited to legal proceedings, law enforcement reasons, Public Health reasons or 'Duty to Warn') requires that we get you to sign a separate authorization allowing for this release. That means for example, that if you move and want to go to another clinician outside our system, we will ask you to sign an authorization before we forward your record to anyone else.

B.

Disclosures For Payment

1. We are allowed to use your information for the purpose of payment. This means that office and billing staff may use the minimum necessary amount of your information to collect payment from any insurer, government program or any other payor including yourself.

2. At times an insurance company or other payor requires us to send them a medical record for their review before they will pay a claim for services rendered by us. When such a request occurs, we review your record and send them only the minimum necessary amount of information that in our opinion satisfies their needs.

3. However, by contract with both you as the member and us as the provider, most plans have a contractual right to review your entire record on demand. If they make such a demand, we must comply. If you wish further information about this process, please call William Berez, Ph.D., our Privacy Officer at (423) 714-2200 and press 8.

C.

Disclosures For Healthcare Operations

1. We are allowed to use your information in the course of our healthcare operations. This means, for instance, that we can use your information to help us schedule, order supplies, review for Quality Assurance or Risk Management or Corporate Compliance or any other way that we see fit to help us carry out, measure and improve the quality of care that we provide.

2. At times it is necessary to mail, fax or electronically transmit your personal health information for the purposes of treatment, payment or healthcare operations. For instance, you are being treated at another facility in an emergency and we must provide your medical record to the treating facility to aid in your treatment. In such a case and other cases, we may fax your record in whole or in part. If we do so, we will make an effort to ensure that the fax is going where it is intended and being used for its intended purpose.

3. Similarly, at times it is necessary to transfer your information between our locations or to an insurance company, governmental agency or other payor and we will use reasonable and appropriate security measures whether they are being transferred physically or electronically. If your record is maintained in electronic form, reasonable and appropriate measures will be taken to protect your personal information, access being allowed only to the minimum necessary extent that each staff member needs to be able to make their best contribution to your care. Precautions will be taken to prevent unauthorized access both within our company and from outside our company. If you have questions about these reasonable and appropriate measures please contact William Berez, Ph.D., our Privacy Officer at (423) 714-2200 and press 8.

VII.  

We will only release your records under the above circumstances. Any other uses and disclosures will be made only with your authorization.

A. If you give us an authorization and later change your mind, you can revoke (cancel) that authorization.

B. If you sign and then later cancel an authorization we will between the time of the authorization and the revocation (cancellation) be allowed to release your record as stated in the authorization that you signed.

C. If we are at some point required by law to release your records to a government agency, such as law enforcement, the Department of Child and Family Services or to Public Health authorities for example, or for any other reason, we are required to keep an accounting of all releases not covered under this statement of practices or by a separate authorization. You have the right to view a list of these releases. Please contact William Berez, Ph. D., our Privacy Officer at (423) 714-2200 and press 8.

VIII.  

You can request restrictions in the handling of your information contrary to the practices described in this notice. Any request of this nature must be made in writing to William Berez, Ph.D., 6350 West Andrew Johnson Hwy. Talbott, TN 37877.

A. Be aware that as we are already committed to keeping your information as private as possible, that any further restriction may interfere with your treatment, our right to pursue payment from a plan or insurer and may hinder our healthcare operations.

B. Such an added restriction may cause responsibility for payment to
fall exclusively to you.

C. In certain circumstances we are not required to honor your request. If we feel that for whatever reason we can't do as you ask, we will explain our reasons to the best of our abilities.

IX.  

You have the right to review or receive a copy of your medical record.

A. You must make this request in writing to: William Berez, Ph.D., 6350 West Andrew Johnson Hwy. Talbott, TN 37877.

B. We will respond to your request within ten days.

C. There will be a charge for this service based on our actual copying charges. We will tell you how much the charge will be at the time of your request.

D. If your are a behavioral health client, due to the possible complexity of your record, we would like for there to be clinician available to review and explain your record to you so those record disclosures will require you to visit one of our locations by appointment. There will be no added charge for this service.

X.   If you do not agree with something in your medical record you have the right to amend it.

XI.  

We will require our Business Associates, persons or companies who perform services for us in the areas of treatment, payment or healthcare operations, to sign statements of acknowledgement to and agreement with our Privacy Practices.

A. In the future we may include these agreements in contracts with our Business Associates.

B. Our Business Associates, whether information is shared with them incidentally or in the course of treatment, payment or healthcare operations, agree to protect your privacy in the same ways that we do by signing these specific agreements.

XII.   We will never use or share your personally identifiable health information with anyone for marketing or research purposes without clearly explaining to you how your information will be used and having you sign an authorization for this use ahead of time. Any information that we share without a specific authorization outside the reasons stated in this Statement will be de-identified (meaning that we will remove all personal information).

XIII.  

If you feel that your privacy has been violated please contact: William Berez, Ph.D., our Privacy Officer at (423) 714-2200 and press 8.

A. It is our desire to immediately address your concerns.

B. However, if your concerns are not addressed to your satisfaction you may complain to the Secretary of Health and Human Services, HHH Building Washington, D.C. 20201.

XIV.   This notice is available in both English and Spanish.

XV.   If you would like more information or further explanation of our privacy practices please call William Berez, Ph.D., our Privacy Officer at (423) 714-2200 and press 8.

Cherokee Health Systems, Inc.
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