NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PERSONAL MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW ACCESS TO THIS INFORMATION CAN BE OBTAINED. PLEASE REVIEW IT CAREFULLY.

This notice is to explain the rules around the privacy of personal medical/health records and our legal duties on how to protect the privacy of the medical/health records that Woodland Spring Lodge creates or receives. Generally, Woodland Spring Lodge, a program of Boys & Girls Town of Missouri, is required by law to ensure that medical/health information that identifies an individual is kept private. Woodland Spring Lodge is required by law to follow the terms of the notice that are the most current.

This notice will explain:

• how Woodland Spring Lodge may use and disclose medical/health information,
• Woodland Spring Lodge's obligations related to the use and disclosure of medical/health information and
• an individual's rights related to any medical/health information that Woodland Spring Lodge possess.

This notice applies to the medical/health records that are generated in or by this organization. The terms "medical" and "medical/health" in this Notice means information about any physical or mental condition for which Woodland Spring Lodge provides services, or which arise while Woodland Spring Lodge is providing services. For example, this may include psychological tests, psychiatric assessments or medical or social assessments.

Woodland Spring Lodge may obtain, but Woodland Spring Lodge is not required to consent for the use or disclosure of protected health information for treatment, payment or health care operations. Woodland Spring Lodge is required to obtain authorization for the use or disclosure of information for other specific purposes or reasons. Woodland Spring Lodge has listed some of the types of uses or disclosures below. Not every possible use or disclosure is covered, but all of the ways that Woodland Spring Lodge is allowed to use and disclose information will fall into one of the categories.

If therefore, any questions about the content of this Notice of Privacy Practices, or if there is a need to contact someone at the organization about any of the information contained in this Notice of Privacy Practices, contact is:

Privacy Officer
Woodland Spring Lodge
P.O. Box 189
St. James, MO 65559-0189
(573)265-3251

In addition to Woodland Spring Lodge departments, employees, staff and other organization personnel, the following people will also follow the practices described in this Notice of Privacy Practices:

• Any health care professional who is authorized to enter information in a medical/health record;
• Any member of a volunteer group that is permitted to assist in Woodland Spring Lodge program/services
• All providers that Woodland Spring Lodge organizations contract with to provide services

The class of entities that make up continuum of care and services are:

• any federal/state-operated departments;
• any administrative agents and contract providers located within federal/state-operated departments; and
• contract providers of Woodland Spring Lodge

In addition, individuals and providers who are Woodland Spring Lodge's Continuum of Care and Services may share medical information with each other about Woodland Spring Lodge clients they serve in common for the purpose of treatment, payment or health care operations as those terms are described later in this Notice of Privacy Practices. These other individuals and providers who are in Woodland Spring Lodge's Continuum of Care and Services are included throughout this document whenever we use the term "Woodland Spring Lodge."

HOW WOODLAND SPRING LODGE MAY USE AND DISCLOSE MEDICAL INFORMATION

The following categories describe different ways that Woodland Spring Lodge uses and discloses medical/health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Woodland Spring Lodge is permitted to use and disclose information will fall within one of the categories.

Use and Disclosure of Medical Information

Woodland Spring Lodge can use or disclose medical information regarding treatment, payment for services, or for organization operations, and Woodland Spring Lodge will make a good faith effort to have clients acknowledge their copy of the Notice of Privacy Practices.

Treatment - Woodland Spring Lodge may use medical information to provide treatment or services. Woodland Spring Lodge may disclose medical information to qualified mental health professionals, or to qualified counselors; or technicians, medical students or residents, or other organization personnel, volunteers or interns who are involved in providing services at Woodland Spring Lodge, or interpreters needed in order to make treatment accessible. For example, Woodland Spring Lodge treatment team members will internally discuss medical/health information in order to develop and carry out a plan for services. Different departments of the organization also may share medical/health information in order to coordinate the different things needed, such as prescriptions, medical tests, special dietary needs, respite care, personal assistance, day programs, etc. Woodland Spring Lodge may disclose medical/health information to people outside the organization who may be involved in medical care after clients are disenrolled, such as contractors Woodland Spring Lodge uses to provide services that are part of aftercare, but only the minimum necessary amount of information will be used or disclosed to carry this out.

Payment - Woodland Spring Lodge may use and disclose medical/health information so that the treatment and services received at the organization may be billed to and payment may be collected from the responsible party, an insurance company or a third party through Woodland Spring Lodge. For example, Woodland Spring Lodge may need to provide insurance plan information about psychiatric treatment or habilitation services received at the organization so your insurance plan, or any applicable Medicaid or Medicare funds, will pay Woodland Spring Lodge for the services. Woodland Spring Lodge may tell insurance plans or other payers about a service received in order to obtain prior approval or to determine whether the service is covered. In addition, in order to correctly determine ability to pay for services, Woodland Spring Lodge may disclose personal health information to the Social Security Administration, the Division of Employment Security, or the Department of Social Services.

Health Care Operations - Woodland Spring Lodge may use and disclose medical/health information for organizational operations. These uses and disclosures are necessary to run the organization and make sure that all Woodland Spring Lodge clients receive quality care. For example, Woodland Spring Lodge may use medical/health information for quality improvement to review our treatment and services and to evaluate the performance of Woodland Spring Lodge staff. Woodland Spring Lodge may combine medical information about many clients to decide what additional services Woodland Spring Lodge should offer, what services are not needed, and whether certain new treatments are effective. Woodland Spring Lodge may disclose information to doctors, nurses, technicians, medical students and residents, and other organization personnel as listed above for review and learning purposes. Woodland Spring Lodge may combine the medical/health information with medical/health information from other facilities to improve performance. It may also be necessary to obtain or exchange information with the Department of Elementary and Secondary Education, the Department of Social Services, Vocational Rehabilitation, the Office of State Courts Administrator, or other state agencies or interagency initiatives. Or Woodland Spring Lodge may remove personal health identifiers from this set of medical information so others may use it to study health care and health care delivery without learning the identity of specific clients. This may be in the form of providing information to the Woodland Spring Lodge Board of Directors or Regional Board of Trustees.

Uses and Disclosures of Medical/Health Information That Do Not Require Consent or Authorization:

Woodland Spring Lodge can use or disclose health information without consent or authorization when:

• there is an emergency or when required by law to treat you,
• when Woodland Spring Lodge is required by law to use or disclose certain information, or
• when there are substantial communication barriers to obtaining consent.

Woodland Spring Lodge can also use or disclose health information without consent or authorization for:

Appointment Reminders

Medical information may be used as a reminder for appointments for treatment or other services.

Treatment Alternatives and Health-Related Benefits and Services

Medical information may be used or disclosed to recommend possible treatment options or alternatives or health-related benefits or services.

Individuals Involved in Disaster Relief

Should a disaster occur, Woodland Spring Lodge may disclose medical information to any agency assisting in a disaster relief effort so that clients can be notified about any condition, status and location.

Research

Woodland Spring Lodge may use and disclose medical/health information for research purposes when approved by Woodland Spring Lodge's internal review process.

As Required By Law

Woodland Spring Lodge will disclose medical/health information when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety

Woodland Spring Lodge may use and disclose medical/health information when necessary to prevent a serious threat to the health and safety of clients, the public, or any other person.

However, any such disclosure would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Public Health Risks

Woodland Spring Lodge may disclose medical/health information for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a consumer has been the victim of abuse, neglect or domestic violence. Woodland Spring Lodge will only make this disclosure if client agrees or when required or authorized by law.

Lawsuits and Disputes

Woodland Spring Lodge may disclose medical/health information in response to a court or administrative order.

Law Enforcement

Woodland Spring Lodge may release medical/health information if asked to do so by a law enforcement official. Woodland Spring Lodge may also release limited medical/health information to law enforcement in the following situations: (1) about a client who may be a victim of a crime if, under certain limited circumstances, Woodland Spring Lodge is unable to obtain agreement; (2) about a death Woodland Spring Lodge believes to be the result of criminal conduct; (3) about criminal conduct at the organization; (4) about a client who commits or threatens to commit a crime on the premises or against program staff (in which case Woodland Spring Lodge may release the client's name, address, and last known whereabouts); (5) in emergency circumstances, to report a crime, the location of the crime or victims, and the identity, description and/or location of the person who committed the crime. However, if the material is protected by 42 CFR Part 2 (a federal law protecting the confidentiality of drug and alcohol abuse treatment records), a court order is required.

RIGHTS REGARDING MEDICAL/HEALTH INFORMATION

Client rights regarding medical information:

Right to Inspect and Copy

Clients have the right to inspect and copy medical/health information with the exception of psychotherapy notes and information compiled in anticipation of litigation. A written request is required to inspect and copy medical/health information. This request is submitted to the Privacy Officer or designee. Woodland Spring Lodge will charge a fee for the costs of copying, mailing or other supplies associated with the request. Woodland Spring Lodge may deny requests to inspect and copy in certain limited circumstances. If client is denied access to medical/health information, a review may be requested. An executive staff person of Woodland Spring Lodge will review the request and the denial.

Right to Request an Amendment

If the medical/health information is thought to be incorrect or incomplete, a request to amend the information may be submitted. Requests for an amendment must be made in writing and submitted to the Privacy Officer or designee.

Right to an Accounting of Disclosures

To request an accounting of disclosures, a written request must be submitted to the Privacy Officer or designee. The request must state a time period, which may not go back more than six years and cannot include dates before April 14, 2003.

Right to Request Restrictions

To request a restriction on the use or disclosure of medical/health information for treatment, payment or health care operations, submit the request in writing to the Privacy Officer or designee. The request must include: (1) what information to limit; (2) whether the limitation is for our use, disclosure or both; and (3) to whom the limits are to be applied. Although Woodland Spring Lodge is not required to agree to the request, if Woodland Spring Lodge agrees, Woodland Spring Lodge will comply with the request unless the information is needed to provide emergency treatment.

If you wish to exercise any of these rights, please contact:

Woodland Spring Lodge Privacy Officer
P.O. Box 189
St. James, MO 65559

CHANGES TO THIS NOTICE

Woodland Spring Lodge reserves the right to change this notice.

COMPLAINTS

To file a complaint with Woodland Spring Lodge, contact Privacy Officer or Designee, at the following address.

Woodland Spring Lodge Privacy Officer
P.O. Box 189
St. James, MO 65559

If you believe your privacy rights have been violated,

A grievance with the Office of Civil Rights by calling 866-OCR-PRIV (866.627.7748), or 886.788.4989 TTY.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OR DISCLOSURES OF MEDICAL/HEALTH INFORMATION

Uses or disclosures not covered in this Notice of Privacy Practices will not be made without written authorization. If Woodland Spring Lodge is provided with written authorization to use or disclose information, parties can change their mind and revoke the authorization at any time, as long as it is in writing. If authorization is revoked, Woodland Spring Lodge will no longer use or disclose the information. However, Woodland Spring Lodge will not be able to take back any disclosures that Woodland Spring Lodge has made pursuant to previous authorization.