Columbiana County Mental Health and Recovery Services Board

• Name, Address, Phone
• Date of Birth
• Marital Status
• Social Security Number
• Family Income

• Health care providers (doctors, clinics, hospitals)
• Other Community Mental Health Boards; Alcohol and Drug Addiction Services Boards; Alcohol and Drug Addiction and Mental Health Services Boards that provide coverage to our clients
• Business partners (companies with whom we have arrangements to assist us in providing products and services)
• Other government agencies (criminal justice system, child welfare, juvenile justice, etc.

Payment for Mental Health Services: We keep records that include payment information and documentation of the services provided to you.  Your information may be used to obtain payment for your services from Medicaid, insurance or other sources.  For example, we may disclose personal information about the services provided to you to confirm your eligibility for Medicaid and to obtain payment from Medicaid.

Health Care Operations: We use personal information to train staff, manage costs, conduct required business duties, and make plans to better serve you and other community residents who may need mental health or substance abuse services.

Other Services We Provide: We may also use your personal information to:

$    Review and evaluate the quality, effectiveness, and efficiency of the services you have received;

$    Conduct program and fiscal audits of programs which have provided you with services;

$    Investigate major unusual incidents, report these kind of incidents and take steps to protect your health and safety;

$    Prepare reports required by the Ohio Department of Mental Health, the Ohio Department of Alcohol and Drug Addiction Services, and the Ohio Department of Job and Family Services;

$    Contact you for assistance in passing levies, unless you notify the Columbiana County Mental Health and Recovery Services Board that you do not wish to be contacted for these purposes.

Sharing Your Personal Information: There are limited situations when we are permitted or required to disclose personal information without your signed authorization.  These situations are:

$    To reduce or prevent a serious threat to public health and safety;

$    For health oversight activities such as investigations, audits, and inspections;

$    For local, state, federal agencies to monitor your services;

$    For lawsuits and similar proceedings;

$    For public health purposes such as reporting communicable diseases, work-related illnesses, or other diseases and injuries permitted by law; reporting births and deaths, and reporting reactions to drugs and problems with medical devices;

$    When required by law;

$    When requested by law enforcement as required by law or court order, except as limited by laws regarding disclosure of alcohol and other drug treatment;

$    To coroners, medical examiners, and funeral directors;

$    For organ and tissue donation;

$    For workers’ compensation or other similar programs if you are injured at work and are covered by workers’ compensation or other similar programs;

$    For specialized government functions such as intelligence and national security.

We maintain physical, electronic, and procedural safeguards that comply with applicable federal and state laws and regulations to guard your personal information against unauthorized use or disclosure.  Any third party processor or consultant used by the Columbiana County Mental Health and Recovery Services Board has signed an agreement with us requiring such entity to maintain the confidentiality of your personal information.  We also restrict access to your personal information to those employees who need to know the information in order to perform their job duties.  The Columbiana County Mental Health and Recovery Services Board maintains policies and procedures that prohibit employees and agents of the Columbiana County Mental Health and Recovery Services Board from using, disclosing, transferring, providing access to or otherwise divulging client health information to any person or entity other than to the individual who is the subject of the information.

You have the following rights regarding the health information we maintain about you:

·        Right to Request Restrictions.  You have the right to request a restriction or limitation on the health information we use or disclose about you for payment or health care operations.  We will consider all requests for restrictions carefully but are not required to agree to any requested restrictions.

You also have the right to request a limit on the health information we disclose about you to a family member who is involved in your care if you are receiving mental health services and have previously agreed to limited disclosure to such a family member.  We will comply with any restrictions you request regarding disclosure to such a family member.*

$    Right to Request Confidential Communications.  You have the right to request that we communicate with you about health matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.

$    Right to Inspect and Copy.  You have the right to access the personal information we collect upon request.  Under certain circumstances, we may not share information that we collected.  For example, if the information is the subject of a lawsuit or legal claim, or if release of mental health information may present a danger to you or someone else.  Fees may apply to copied information.*

$    Right to Amend.  You have the right to request corrections or additions to your personal information.  You must give reasons for wanting the change.*

$    Right to An Accounting of Disclosures.  You have the right to request an accounting of disclosures made of your personal information that were not related to Columbiana County Mental Health and Recovery Services Board operations or your authorization. Under certain circumstances, we may not share information that we collected, for example, if the information is the subject of a lawsuit or legal claim or if release of the information may present a danger to you or someone else.  Your request must state the period of time desired for the accounting, which must be within the six years prior to your request.  The first accounting is free, but a fee will apply if more than one request is made in a 12-month period.*

$    Right to a Paper Copy of Notice.  You have the right to a paper copy of this Notice.  You may obtain a copy of the Notice by contacting the Columbiana County Mental Health and Recovery Services Board office.

Requests marked with an asterisk (*) must be made in writing.  Contact the Columbiana County Mental Health and Recovery Services Board Privacy Officer with your request.

To exercise any of your rights described in this paragraph, please contact the Board’s Privacy Officer at the address or phone number listed below.

We reserve the right to change this Notice at any time.  We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice at the Columbiana County Mental Health and Recovery Services Board office.  The Notice will contain on the first page in the top center, the effective date.  In addition, each time there is a change in the Notice, you will receive a copy by mail at the last known address we have in our plan enrollment file.

If you have a complaint about our Privacy policies and procedures or you believe your privacy rights have been violated, you may file a complaint with the Columbiana County Mental Health and Recovery Services Board or with the Secretary of the Department of Health and Human Services.  To file a complaint with the Columbiana County Mental Health and Recovery Services Board, contact the privacy Officer at the address below.  We will investigate all complaints and will not retaliate against you for filing a complaint.  If you wish to file a complaint with the Secretary, you may send the complaint to:

Other uses and disclosures of your personal health information not covered by this Notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written permission.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the services that we provided to you.

(330) 424-0195