Notice of Privacy Practices

Comprehensive Mental Health Services is proud
to be a Burrell Health Center.

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. This notice applies to Burrell Inc., including its affiliates and subsidiaries. (Collectively “Burrell”).

Burrell’s Duties
By law, Burrell must keep protected health information (PHI) private. PHI is any
information, including verbal, electronic and on paper that is created or received by Burrell for purposes of providing health care to patients and for purposes of billing and payment for those services. PHI includes test results, notes written by doctors, nurses and other clinical staff, and general information such as your name, address and telephone number that is included in your health care records and your billing records. Burrell is required by law to give you this notice and to follow the notice that is currently in effect.

The Health Care Providers Covered By This Notice
This notice covers Burrell and all staff, volunteers, students and trainees.

Use and Disclosure of PHI Without Your Permission
Below is a list of ways in which Burrell may use or share your PHI without your advance permission:

• For Treatment: We may share PHI about you with people in your care. For example, a doctor may need to look at your medical history before treating you.
• For Payment: We may use and disclose your PHI for billing purposes. For example, we may share your PHI with your insurance company to receive payment for services Burrell provides to you, and we may share information with an ambulance company so that it may bill for services provided to bring you to Burrell for treatment.
• For Health Care Operations: We may use and disclose PHI about you for our operations. For example, we may share PHI about you to evaluate our staff’s performance in caring for you.
• For Research: We may share your PHI with researchers when their research has been approved by an institutional review board (IRB) and found by the IRB not to require patient permission. Your permission is required for other types of research.
• Public health activities such as to report the occurrence of communicable diseases.
• To report information about victims of abuse, neglect or domestic violence.
• Health oversight activities, such as Medicare and Medicaid program activities.
• Legal proceedings, such as in response to a subpoena or court order.
• Law enforcement purposes, such as with the police or other law enforcement officials who are pursuing a criminal suspect.
• With medical examiners, coroners, and funeral directors.
• For organ and tissue donation purposes.
• To avert a serious health or safety threat.
• To comply with workers’ compensation laws.
• With an entity legally authorized to assist in disaster relief efforts such as the American Red Cross.
• For other purposes as required by law.

Permissive Uses or Disclosures
Burrell may use or share your PHI for any of the purposes described in this section unless you request in writing that we do not. Your written request must be given to your care provider or to the Privacy Officer listed at the end of this notice.

• We may contact you to remind you of an appointment.
• We may contact you to tell you about or recommend possible treatment
  options or alternatives that may be of interest to you.
• We may contact you about Burrell-sponsored activities including fundraising programs and events. If you do not want your information to be used for fundraising purposes, please contact the Burrell Foundation office listed at the end of this notice. We will care for you regardless of your decision to participate in fundraising activities.
• We may share PHI about you with a friend, family member, personal representative, or any individual you identify who is involved in your care or is paying for some or all of your care.

Uses and Disclosures Requiring Your Written Permission
For any purpose other than the ones listed earlier in this notice, we may use or share your PHI only when you give us written permission.

Psychotherapy Notes
We must obtain your written permission for most uses and disclosures of psychotherapy notes.

Marketing
Before we receive financial payment for marketing activities using your PHI, we must obtain your written permission. We may, however, communicate with you about products or services related to your treatment, case, case management, care coordination, or alternative treatments, therapies, health care providers or care settings without your permission. Your permission is also not needed for small promotional items and face-to-face communications.

Sale of PHI
We may not sell your PHI without your written permission, except that we may be paid our cost to provide PHI for certain purposes such as public health purposes and other purposes permitted by HIPAA.

Revoking Your Authorization.
If you give us written permission to use and share your PHI, you can take back your permission at any time, as long as you tell us in writing. If you take back your permission, we will stop using or sharing your information, but we will not be able to take back any information that we have already shared.

YOUR RIGHTS

Right to Request Restrictions
You can ask us not to use or share certain health information. We are not required to agree to your request and may say “no” if it would affect your care. If you pay cash for your health care item or service in full and request that Burrell not to share the PHI about that service with your health plan, we will not disclose the PHI about that service to the health plan unless we are required to do so by law.

Right to Request Confidential Communication
You have the right to request PHI in a certain form or at a specific location. Your
request must be in writing. For example, you can request that we not contact you at work, and you can tell us how and/or where you want to receive PHI. We will agree to reasonable requests. If we agree to your request, we will honor your request until you tell us in writing that you have changed your mind and no longer want the confidential communication.

Right to Inspect and Receive a Copy Your PHI
You have the right to review your PHI and to receive a paper or electronic copy of
your PHI. Your request must be in writing if the records are to be released to anyone other than you. We may charge a fee for the cost of providing you with copies. We may deny your request to access and receive a copy of your PHI in rare situations when doing so is determined by a licensed health care professional to pose a serious risk of harm.

Right to Request a Change to Your PHI
You have a right to request that your PHI be corrected if you believe that it contains a mistake or is missing information. You must tell us the reasons for the change in writing using the request form you can get from your provider or from the Privacy Officer listed at the end of this notice. Burrell can deny your request if: (1) it is not in writing or does not include a reason for the change; (2) the information you want to change was not created by Burrell; (3) the information is not part of the medical record kept by Burrell; (4)the information is not part of the information that you are permitted to inspect or copy; or (5) the information contained in the record is accurate and complete.

Right to Notice of a Breach
We are required by law to tell you if there is a breach of your PHI. A breach can occur when safeguards to protect your PHI fail.

Right to an Accounting of Disclosures
You have the right to request an accounting of disclosures of your PHI that we have made, with some exceptions. Your request must be in writing and must state the time period for the requested information.

Burrell will not provide this information for a time period greater than six (6) years from the date of your request. You have the right to receive one (1) free accounting every twelve (12) months. If you request more than one (1) accounting in any twelve (12) month period, we may charge you a reasonable fee for the costs of providing that list.

Right to Receive a Copy of this Notice
You have the right to a copy of this Notice. You may view and print a copy of this
notice from our website at burrellcenter.com/hipaa-privacy-policy. If you want a
paper copy of this notice mailed to you, or to exercise any of your rights outlined
above, please send a written request to the Burrell Privacy Officer listed at the end of this notice.

We will not share any substance use disorder treatment records without your written authorization unless permitted under 42 CFR Part 2 or otherwise required by law.

Privacy Complaints
If you have any questions about this notice, or any concern about the privacy of your PHI, please contact the Burrell Privacy Officer listed at the end of this notice.

We hope you will tell us if you have a concern so we can try to fix it, but you also
have the right to file a complaint with the Office for Civil Rights (OCR). If you decide to report a complaint to Burrell or to the OCR this will not affect your ability to obtain care and treatment at Burrell.

Changes to this Notice
We have the right to change this notice at any time. If we change this notice, we
may make the new terms effective for all PHI that we maintain. Any changes that we make will comply with federal, state and other laws. The most recent copy of this notice will be on our website. You can also call or write the Privacy Officer listed at the end of this notice to obtain the most recent version of this notice.

Nondiscrimination Notice
Burrell values diversity and inclusion and is proud to welcome clients and employees of all diversity types. Burrell does not and will not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity or expression, national origin, ancestry, age, protected veteran status, disability status, political affiliation or belief, genetics, marital status, pregnancy status, or any other legally protected status. Burrell also does not discriminate in the provision of services to an individual based on: the individual’s inability to pay; whether payment for those services would be made under Medicare, Medicaid, CHIP, commercial insurance or private pay. We are passionate about and committed to building a safe and welcoming environment for all employees and clients. Discrimination is against the law. Burrell Behavioral Health complies with applicable Federal civil rights laws as well as state and other regulatory requirements. Burrell Behavioral Health welcomes all individuals and treats clients and employees with dignity and respect. Burrell provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters; and Written information in other formats (large print, audio, accessible electronic formats and other formats).
• Burrell provides free language services to people whose primary language is
  not English, such as:
• Qualified interpreters; and Information written in other languages.

If you need these services, contact the Section 1557 Coordinator listed at the end of this notice. If you believe that Burrell has failed to provide these services or discriminated in another way on the basis of race and ethnicity, color, national origin, age, ability/disability, marital status, pregnancy, sex, gender identity or expression, or sexual orientation, you can file a grievance with the Section 1557 Coordinator listed at the end of this notice. If you need help filing a grievance, the Burrell Client Advocate is available to help you and can be reached at the phone number or email listed at the bottom of this notice. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal. hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, (800) 537- 7697(TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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