NEW CLIENT PAPERWORK

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Information regarding your health care, including payment for healthcare, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.C.S.-1320d et seq., 45 C.F.R. parts 160 & 164, and the Confidentiality law, 42 U.S.C.- 290dd-2, 42 C.F.R. Part 2. Under these laws, AVO Behavioral Health, Inc. (AVO) may not say to a person outside AVO that you attend the program, nor may AVO disclose any other protected information except as permitted by federal law.

AVO must obtain your written consent before it can disclose information about you for payment purposes. For example AVO must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before AVO can share information for treatment purposes or for health care operations. However, federal law permits AVO to disclose information with out your written permission:

1. Pursuant to an agreement with a      qualified service organization business associate;
2. For research, audit or evaluation
3. To report a crime committed on AVO      premises or against AVO personnel;
4. To medical personnel in a medical      emergency;
5. To appropriate authorities to      report suspected child abuse or neglect;
6. As allowed by a court order.

For example, AVO can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a qualified service organization / business associate agreement in place.

Before AVO can use or disclose any information about your health in a manner, which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. You may revoke any such written consent in writing. 

YOUR RIGHTS

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. AVO is not required to agree to any restriction you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency.

You have the right to request that we communicate with you by alternative means or at an alternative location. AVO Behavioral Health, Inc. will accommodate such request that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy your own health information maintained by AVO Behavioral Health, Inc., except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. 

Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in AVO Behavioral Health, Inc. records, and to request and receive an accounting of disclosures of your health related information made by AVO Behavioral Health, Inc. during the six years prior to your request. You also have the right to receive a paper copy of this notice.