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AFFORDABLE CARE ACT SECTION 1557 NOTICE AND TAGLINES
Crestwood Behavioral Health, Inc. (“Crestwood”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Crestwood does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact our Civil Rights Coordinator, John Allen, at (916) 471-2248.
If you believe that Crestwood has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: John Allen, Civil Rights Coordinator, Crestwood Behavioral Health, Inc., 520 Capitol Mall, #800, Sacramento, CA 95814, (916) 471-2248, fax: 916-471-2212, email@example.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.
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.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-873-6239.
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք
توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните
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ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ।
ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-844-873-6250.
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau
ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं।
เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร
NOTICE 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.
If you have any questions about this notice, or need further information, please contact the Privacy Officer:
YOUR HEALTH INFORMATION:
During the course of providing services and care to you, we gather, create, and retain certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is characterized as your “protected health information.” This Notice of Privacy Practices describes how we maintain the confidentiality of such information, and informs you about its possible uses and disclosures. It also informs you about your rights with respect to your health information.
WHO WILL FOLLOW THIS NOTICE:
This notice describes our facility’s practices and that of:
- Any health care professional authorized to enter information into your medical record;
- All departments and units of the facility;
- Any member of a volunteer group we allow to help you while you are in the facility
- All employees, staff and other facility personnel; and
- All other facilities owned and/or operated by Crestwood Behavioral Health,
All of these entities, sites and locations follow the terms of this notice.
In addition, these entities, sites and locations may share medical information with each other for treatment, payment or facility operation purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting the privacy of health information about you. We create a record of the care and services you receive in our facility. We need this record to provide you with quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated by the facility, whether made by facility personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.
This notice explains to you the ways in which we may use and disclose health information about you. This notice also describes your rights and certain obligations we have regarding the use and disclosure of health information.
We are required by law to:
- Make sure that health information that identifies you is kept private;
- Give you this notice of our legal duties and privacy practices with respect to health information about you; and
- Follow the terms of the notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
If you are conserved under the Lanterman-Petris-Short Act (LPS Act), California state law places special restrictions on the release of information and records obtained in the course of providing services for mental health and developmental disabilities that in some cases imposes greater restrictions on uses and disclosure of health information than is required by federal law. In those instances where state law is more stringent, our facility will follow state law.
The following describes different ways that we use and disclose health information about you. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment: We may use health information about you to provide you with medical and/or mental health treatment or services. We may disclose health information about you to professionals within the facility who are providing services to you or other facility personnel who are involved in taking care of you at the facility. For example, different departments and or associates of our facility also may share health information about you in order to coordinate your care. We may also disclose health information about you to qualified professionals outside the facility, who have medical or psychological responsibility for your care, or to outside services such as pharmacy for prescriptions, an outside laboratory for laboratory tests and x-rays. When required, we will obtain your authorization before disclosing any of your information. Only the minimum amount of information required will be revealed during any disclosures.
Payment: We may use and disclose health information about you so that the treatment and services you receive at this facility may be billed to, and collected from, you, an insurance company, or a third party. The records and information will be disclosed only to the extent necessary to make the claim for payment. For example, we may need to provide a health insurer or third party payer information about the care that you received at the facility so that we may be paid or you may be reimbursed for the services we have provided to you. We may also tell your insurance company about a treatment you are going to receive, to obtain prior approval or to determine if your plan will cover the treatment. In the event that you request it, we will not disclose your health information to a health insurer or third party payer regarding care paid for out-of-pocket by you or someone else.
Health Care Operations: We may use and disclose health information about you for operational purposes. Such disclosures may be made to members of the facility’s medical staff, or to our risk or quality improvement personnel to evaluate the performance of the facility staff, assess the quality of care and outcomes in your case and similar cases, learn how to improve our facility and its services, and determine how to continually improve the quality and effectiveness of the health care we provide.
Appointment Reminders/Treatment Alternatives/Health Related Benefits: We may use and disclose medical information to you to provide appointment reminders, information about treatment options or alternatives or other health related services that may interest you.
Facility Directory: We may maintain a directory of clients in the facility that contains the client’s name, room number, general condition in general terms (good, fair, poor) that does not communicate specific medical information about you and any religious affiliation.
Business Associates: We may contract with certain individuals or entities, called “business associates,” to provide services to us. Examples include data processing, quality assurance, legal, or accounting services. We may disclose your health information to a business associate, as necessary, to allow the business associate to perform its functions. We will have a contract with each business associates that obligates it to maintain the confidentiality of your health information.
Sale of Health information: We may disclose your health information for remuneration in certain very narrow circumstances such as where a governmental agency reimburses us for our expenses in providing information for public health purposes. Otherwise, we will obtain a specific written authorization from you or your personal representative before receiving reimbursement for using or disclosing your health information.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to the persons you placed on your notification list, or your responsibility party. These names may include friends or family members who are involved in your medical care or someone who helps pay for your care. When allowed, we may also tell your family or friends your condition. In addition, we may disclose the minimum necessary medical information about you to persons assisting in a disaster so that your family can be notified about your condition, status and location.
As Required By Law: We may use and disclose information about you as required by law. For example, we may disclose information for judicial and administrative proceedings pursuant to legal authority; to report information related to victims of abuse, neglect or domestic violence; and to assist law enforcement officials in their law enforcement duties as permitted by law.
To Avert a Serious Threat to Health and Safety: We may use and disclose minimally necessary health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Such information will only be disclosed to the extent permitted by law.
Organ and Tissue Donation: If you are an organ donor, we may release minimum necessary information about you to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release minimally necessary health information about you as required by military command authorities.
Workers Compensation: We may release minimally necessary health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. State and/or federal law control the release of such information.
Public Health Risk: We may disclose medical information about you for public health activities to the extent permitted by law.
These activities generally include the following:
- To prevent or control disease, injury or disability;
- To report births or deaths;
- As necessary to comply with statutory requirements regarding the prevention, investigation or treatment of elder and dependent adult abuse. Only information that is necessary to comply with the reporting law may be released;
- To report reactions to medication 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 client has been the victim of domestic violence. We will only make this disclosure if you agree or when required by law.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose necessary health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process to the extent permitted by law.
Law Enforcement: We may release health information about you if asked to do so by a law enforcement official:
- In response to a court order, subpoena, summons or similar process to the extent permitted by law;
- When a warrant of arrest is personally lodged with the facility showing that the person sought is wanted for a serious felony, or a violent felony. The information sought and released must be limited to whether or not the person named in the arrest warrant is presently confined in the facility;
- When a client, who is a criminal defendant and has been committed following a determination that he or she is incompetent to stand trial, has disappeared from the facility;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- To report a crime that the facility has probable cause to believe was committed by a client while hospitalized in the facility.
Coroners and Medical Examiners: We may also release health information about you to a coroner or medical examiner. This may be necessary for example to identify a deceased person or to determine the cause of death.
National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Protective Services for the Client and Others: We may release or disclose health information about you to authorized federal officials so they may provide protection to the Client, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release necessary medical information about you to the correctional institution or law enforcement official. This release would be necessary for:
- This facility to provide you with health care;
- To protect your health and safety or the health and safety of others;
- For the safety and security of the correctional institution.
OTHER USES OF HEALTH INFORMATION WITH WRITTEN AUTHORIZATION: Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. An authorization is generally required for the following uses or disclosures, except in very limited circumstances: (1) uses or disclosures of psychotherapy notes; (2) uses or disclosures of health information for marketing purposes; and (3) disclosures of health information that constitute its sale. We have prepared an authorization form for you to use that permits us to use or disclose your health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. We then will not use or disclose your health information, except where we already have relied on your authorization.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records. It does not include psychotherapy notes where it is determined that access would bring a substantial risk of adverse consequences to you. It also does not include more general psychiatric information where it is determined that access is likely to endanger your life or physical safety or the life or physical safety of another person.
To inspect and copy health information that may be used to make decisions about you, you will be asked to submit a written request to the facility administrator. If you request a copy of the information, we may charge a fee for the costs of labor and supplies, together with postage where you request that the copies be mailed.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review your request and the denial. The person conducting the review will not be the person who initially denied your request. The facility will comply with the outcome of the review.
Right to Amend: If you feel that any of health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our facility. An amendment must take the form of an addendum that supplements the health information. You have no right to alter your health information by deleting or revising material in your records.
To request an amendment, your request must be made in writing and submitted to the facility administrator. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing, or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for our facility; or
- Is not part of the information which you would be permitted to inspect and copy.
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures”. This is a list of the disclosures we have made of your health information. We are not required to account for routine disclosures.
To request this list or accounting of disclosures, you must submit your request in writing to the facility administrator. Your request must state a time period, which may not be longer than six years prior to the time of your request. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. To request confidential communications, you must make your request in writing to the facility administrator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To request a paper copy of this notice, please make your request in writing to the facility administrator.
Right to Request Restrictions: Even though all disclosures we make contain the minimum necessary information, you have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. Finally, you have the right to request a restriction on the people who are able to obtain the information we disclose. We are not required to agree to your request, except where you ask us not to disclose information to your medical insurer or third party payer regarding care paid for out-of-pocket by you or someone else. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment.
To request restrictions, you must make your request in writing to the facility administrator. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
NOTICE OF SECURITY BREACHES:
We will provide you with written notification in the event of a security breach involving your health information. The notification will describe what happened, the types of information involved, the steps that we are taking to deal with the situation, what you should do to protect yourself against any harmful consequences, and contacts for obtaining further information.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. 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 may receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top left hand corner, the effective date. In addition, each time you register at or are admitted to the facility for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with our facility administrator and/or Crestwood’s Corporate Office or with Department of Health and Human Services. You will not be retaliated against for filing a complaint. You will be asked to complete a Complaint form.
To file a complaint with Crestwood’s Corporate Office, please contact the Privacy Officer at:
Name: Dawn Capp
Title Privacy Officer
Address: 520 Capitol Mall, Suite 800, Sacramento, CA 95814
Telephone No.: (916) 471-2285