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CHILD AND ADOLESCENT SERVICE CENTER
NOTICE OF PRIVACY PRACTICES
CLIENT RIGHTS and GRIEVANCE PROCEDURES
Thelma Coss, Privacy Officer, Client Rights Advocate
330-452-7640 or voice mail 330-454-7917 x188
Connie Truman, Alternate Client Rights Advocate
330-452-7640 or voice mail 330-454-7917 x242
Notice Regarding the Use and Disclosure of Protected Health Information
Effective April 14, 2003
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This notice describes how medical information about your child may be used and
disclosed and how you can get access to this information. Please review it
carefully.
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This Notice has been prepared by Child and Adolescent Service Center. It tells
you how Protected Health Information about your child can be created, shared,
protected and maintained.
What is my Protected Health Information?
• Anything from the past, present or future;
• About your child’s mental or physical health or condition;
• That is spoken, written, or electronically recorded, and is
• Created by or given to anyone providing care to your child; a health plan; a
public health authority; your employer; your insurance company; your child’s
school or university; or anyone who processes health information about your
child.
What Rights Do I Have About My Protected Health Information?
• You have the right to consent to the use and disclosure of your child’s
Protected Health Information for the limited purpose of diagnosing him/her and
administering and paying for his/her treatment.
• You have the right to authorize the sharing of your child’s Protected Health
Information for other purposes.
• You have the right to see and copy your child’s Protected Health Information.
Exceptions to this information are psychotherapy notes; information prepared for
certain legal proceedings; and information maintained by clinical laboratories.
• You have the right to request that we amend your child’s Protected Health
Information.
• You have the right to be informed about and to share your child’s Protected
Health Information in a confidential manner chosen by you. The manner you choose
must be possible for us to do.
• You have the right to restrict how we use and disclose your child’s Protected
Health Information. We do not have to agree to your restrictions. If we do
agree, we must follow your restrictions.
• You have the right to obtain a copy of a record of certain disclosures of your
child’s Protected Health Information that we make. If you request a copy of the
information, we may charge a reasonable fee for the costs of copying, mailing or
other supplies associated with your request.
• You have the right to have a copy of this Privacy Notice. We may change the
terms of this Privacy notice from time to time. You can always get a copy of the
current Privacy Notice by requesting it from your child’s service provider, from
the Privacy Officer/Client Rights Advocate, Thelma Coss 330-454-7917 x 188, or
from Alternate Client Rights Advocates Connie Truman, Margaret Skelley, Pat
Horowitz, or Joyce Lane, 330-452-7640.
Consent
What can be done with my information if I consent to disclose it for my child’s
diagnosis or to administer and pay for his/her treatment?
With your consent, we can share information about your child’s health with other
specialists so that your child can receive the most appropriate treatment. For
example, your child’s counselor could share with the treating physician that
your child is depressed. The doctor could then prescribe medication to help
him/her feel better.
With your consent, we can share information about when and for what purpose your
child was seen, so that we can be paid for treating him/her. For example, we
could send a form to your insurance company stating when and for what condition
your child was at the office. They can then send us money to help cover the
costs of your child being seen.
With your consent, we can share information with other healthcare entities to
ensure that your child obtains the correct diagnosis. For example, if your child
were complaining about being tired all the time, we could obtain a sample of
his/her blood and sent it to a blood laboratory. The blood laboratory could send
us back information that your child’s blood sample contained high sugar levels.
This could help us determine whether your child has diabetes.
With your consent, we can share information for the purposes of:
Treatment (provision, coordination, or management of health care services;
consultations; or referrals between health care providers);
Payment (activities undertaken to obtain or provide reimbursement or
premiums for the provision of health care and related activities,
including eligibility and coverage determinations, risk adjustments,
billing, claims management, collections, utilization reviews, and
medical necessity reviews;
Operations (services or activities necessary to carry out the agency’s functions
regarding treatment or payment, including but not limited to quality assessment
and improvement activities, business planning and development, legal services
and planning, auditing, accreditation, and licensing activities).
Can I revoke my consent?
Yes. You can revoke your consent. You must do this in writing and bring it to us
so that we can stop using and disclosing your child’s Protected Health
Information. We are permitted to use and disclose your child’s Protected Health
Information based on your consent until we receive your revocation in writing.
However, if you revoke your consent, we reserve the right to refuse to provide
further treatment to your child, on the basis of your refusal to allow us to
share your information for purposes of treatment, payment, and healthcare
operations.
Authorization
What can be done with my child’s information if I authorize its disclosure for
other purposes?
With your permission, we can share your child’s Protected Health Information for
reasons other than to diagnose and to administer and pay for treatment. For
example, you might agree to allow us to share your child’s Protected Health
Information with a drug company so that it can send you information about new
medications to treat your child’s condition.
Can I revoke my authorization?
Yes. You can revoke your authorization. You must do this in writing and bring it
to us so that we can stop sharing your child’s Protected Health Information. We
are permitted to share your child’s Protected Health Information based on your
authorization until we receive your revocation in writing.
Are there circumstances when my child’s information can be shared without my
consent or authorization?
Yes. Your child’s Protected Health Information can be shared without your prior
consent or authorization:
1. In an emergency as long as consent is obtained as soon as possible;
2. When required by law:
• For public health activities;
• To protect victims of abuse, neglect or domestic violence;
• For health oversight activities;
• For judicial and administrative proceedings;
• For law enforcement purposes;
• To a coroner/medical examiner;
• For research purposes;
• To avert serious threats to health or safety;
• To facilitate specialized government functions;
• To correctional institutions for specific reasons;
• To facilitate eligibility determinations or enrollment into public benefit
programs;
• For Workers Compensation;
• To non-custodial parents, upon request, unless this privilege is denied by a
court order;
3. When there are substantial communication barriers and it is reasonable to
believe that you are giving your consent or authorization.
What about any other uses of my child’s Protected Health Information?
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 permission. If you
provide us permission to use or disclose medical information about your child,
you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about your
child for the reasons covered by your written authorization. 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 care that we
provided to your child.
What will you do to protect my child’s health information?
We will maintain the privacy of your child’s Protected Health Information as
required by law. At your request, we will provide you with a Privacy Notice
containing our legal responsibilities and privacy practices regarding Protected
Health Information.
We will follow the terms of the Privacy Notice currently in effect. We reserve
the right to change the terms contained in this Privacy Notice.
If we do this, it will affect all Protected Health Information maintained by us.
We will notify you that we have changed the Privacy Notice by posting it at our
offices, and by mailing it to you at the address you provide.
What can I do if I have questions or want to complain about the use and
disclosure of my child’s Protected Health Information?
All questions and complaints about the use and disclosure of your child’s
Protected Health Information may be sent to:
NAME Thelma L. Coss
TITLE Privacy Officer/Client Rights Advocate
PHONE NUMBER (330) 452-7640
(330) 454-7917 x 188 (voice mail)
ADDRESS 919 Second Street, Northeast
Canton, Ohio 44704
We may not retaliate against you for complaining about the use and
disclosure of your child’s Protected Health Information
CLIENT RIGHTS and GRIEVANCE PROCEDURE
I. INTRODUCTION
All Child and Adolescent employees and workers located at any site where
services or treatment are provided will always strive to provide you, the
individual or family who comes to us for assistance, with quality, timely
services in a setting you find friendly and supportive. As someone who receives
services from our agency, you are entitled, by law, to the opportunity to know
and understand your rights and responsibilities according to law and to Child
and Adolescent Service Center policy. The following information is provided for
your reference. Please do not hesitate to call or write us if you have any
questions or concerns.
II. DEFINITIONS
A. “Client” means a person who has applied for services, or
is receiving or has received mental health services.
B. “Services” means any or all of the following mental health services:
1. Diagnostic Assessment
2. Counseling/psychotherapy
(individual, family, or group)
3. Medical/Somatic
4. Forensic Evaluation
5. Pre-Hospital Screening
6. Crisis Intervention
7. Peer Support
8. Community Support/Case Management
9. Consultation
10. Prevention
11. Mental Health Education
12. Referral and Information
C. “Confidentiality” means the right to privacy of client’s service, treatment,
or records.
D. “Records” means the client’s service/treatment file.
E. “Guardian” means the parent, adult, or agency holding
legal custody of the client.
F. “Agency Client Rights Advocate” means an individual designated by the agency
who assures client-centered advocacy services are provided to people served by
the agency. Duties include protecting the human and civil rights of persons
served and investigating and responding to complaints and grievances.
G. “Complaint” means any concern communicated by a
person questioning the personal care or clinical
treatment received by the person served, the environmental conditions, or any
aspect of services received. A complaint is less formal than a grievance.
H. “Grievance” means a formal request for further review of any unresolved
complaint that may or may not contain allegations of the denial, exercise or
violation of the rights of persons served. A grievance may be initiated either
orally or in writing by a person served, client, ex-client, or any other person
or agency acting on behalf of a person served.
I. “Grievant” means the person(s) who initiates the complaint, grievance and/or
appeal. The grievant may be the client, a parent, a relative, guardian of the
adult person, guardian of a minor child, an advocacy group or other interested
person(s).
J. “Mediation” means a voluntary process in which a neutral
third party meets with persons who have a disagreement or dispute and
facilitates their reaching a mutually satisfactory resolution.
K. “Appeal” means any grievance that remains unresolved to the client’s
satisfaction and for which the client requests a higher level review, hearing,
or re-hearing of the client’s grievance.
L. “Resolution” means the oral or written determination,
answer, and expression of opinion after a review, investigation and analysis of
the concern, directed to the grievant.
III. CLIENT RIGHTS
A. The right to be treated with consideration and respect for
personal dignity, self-determination, and privacy;
B. the right to service in a humane setting which is the least
restrictive feasible as defined in the individualized service plan.
C. the right to be informed of one’s own condition, or proposed or
current services, treatment or therapies, and of the alternatives;
D. the right to consent to or refuse any service, treatment, or therapy upon
full explanation of the expected consequences of such consent or refusal. A
parent or legal guardian may consent to or refuse any service, treatment or
therapy on behalf of a minor client;
E. the right to a current, written, individualized service plan that
addresses one’s own mental health recovery/resiliency,
physical health, social, cultural, and economic needs, and that
specified the provision of appropriate and adequate services,
as available, either directly or by referral;
F. the right to active and informed participation in the establishment, periodic
review, and reassessment of the individualized service plan;
G. the right to freedom from unnecessary or excessive medication;
H. the right to freedom from unnecessary or excessive restraint or
seclusion;
I. the right to participate in any appropriate and available agency
service, regardless of refusal of one or more other services,
treatments, or therapies, or regardless of relapse from earlier
treatment in that or another service unless there is a valid and
specific clinical necessity which precludes and/or requires the
client’s participation in other services. This necessity shall be
explained to the client and written in the client’s current service
plan;
J. the right to be informed of and refuse any unusual or hazardous
treatment procedures;
K. the right to be advised of and refuse to be observed by
techniques such as one-way vision mirrors, tape/video recorders, televisions,
movies, photographs, or any other observation or recording device not used for
building security purposes;
L. the right to consult with independent treatment specialists or
legal counsel, at one’s own expense;
M. the right to confidentiality of communications and of all
personally identifying information within the limitations and
requirements for disclosure of various funding and/or certifying
sources, state of federal law, unless release of information is
specifically authorized by the client or parent or legal guardian
of a minor client or court-appointed guardian of the person of an
adult client;
N. the right to have access to one’s own psychiatric, medical or
other treatment records, unless access to particular identified
items of information is specifically restricted for that individual
client for clear treatment reasons in the client’s service plan.
“Clear treatment reasons” shall be understood to mean only
severe emotional damage to the client such that dangerous or
self-injurious behavior is an imminent risk. The person
restricting the information shall explain to the client and other
persons authorized by the client the factual information about
the client that necessitates the restriction. The restriction must
be renewed annually to retain validity. Any person authorized by
the client has unrestricted access to all information. Clients
shall be informed in writing of agency policies and procedures
for viewing and obtaining copies of personal records;
O. the right to be informed in advance of the reason(s) for transfer,
termination or discontinuance of service provision or provider,
and to be involved in planning for the consequences of that
event;
P. the right to receive an explanation of the reasons for denial of
service;
Q. the right not to be discriminated against in the provision of
service on the basis of religion, race, color, creed, sex,
national origin, age, lifestyle, physical or mental handicap,
development disability, or inability to pay;
R. the right to be fully informed of the cost of services;
S. the right to be fully informed of all rights;
T. the right to file a complaint/grievance or request voluntary
mediation if available, and the right to have oral and written instructions and
assistance in an accessible format for filing a complaint/grievance or
medication;
U. the right to have a properly executed durable medical power of
attorney honored; and
V. the right to exercise any and all rights without affecting
continued and uncompromised access to service and without reprisal in any form.
IV. HOW TO FILE A COMPLAINT/GRIEVANCE
A. The grievance procedure shall be posted in a highly
visible place in each agency location.
B. Upon request, all Child and Adolescent Service Center
(CASC) clients and/or guardians shall be provided with oral and written
instructions for filing a grievance. Any CASC client/guardian who has a concern,
complaint, or grievance should contact Client Rights Advocate, Thelma Coss, at
the Child and Adolescent Service Center, 919 Second Street,
NE, Canton, Ohio 44704, (330)454-7917 x188, or (330)452-7640. Agency business
hours are Monday-Friday 8:00am-5:00pm. The alternate Client Rights Advocate is
Connie Truman, 919 Second Street, NE, Canton, Ohio 44704, (330)454-7917 x 242.
Clients/guardians may also contact the CASC Parent or
Peer Support programs (330)452-7640.
C. CASC shall provide the Client Rights Advocate with
accessibility and all necessary steps to assure compliance
with the grievance procedure. Alternative arrangements will
be made if the Client Rights Advocate is the subject of the
grievance.
V. GRIEVANCE/COMPLAINT PROCEDURES
A. Complaint resolution shall first be routinely attempted
at the lowest possible level of the organization and in
the shortest time possible.
B. Complaints not responded to at the lowest possible
level within five working days shall be referred to the
agency Client Rights Advocate.
C. The grievant has the option to engage in voluntary
mediation at any time during the grievance process.
1. If utilized, the mediation shall occur within ten working
days of the decision by the grievant to request mediation
2. Mediation services shall be provided at no cost
to the client.
3. The grievant or agency Client Rights Advocate
determines that the concern constitutes a
grievance and the person served agrees to pursue
such a grievance.
D. A person served or other interested person can
file a grievance if:
1. The grievant is dissatisfied with the resolution of a complaint and does not
choose mediation;
2. The grievant is dissatisfied with the mediation outcome; or
E. The agency grievance process cannot exceed twenty working days from the
initial oral or written filing of the grievance to the agency’s written
resolution. Within this twenty working day period the following must occur:
1. The grievant shall put the grievance in writing. The grievant may request
assistance from staff or the agency Client Rights Advocate.
2. The grievance shall be delivered immediately to both
the agency Client Rights Advocate and the agency
Chief Executive Officer or his/her designee.
3. The grievant is informed of the option to contact any of the following:
a. Stark County Mental Health Board
800 Market Avenue, North
Canton, Ohio 330-455-6644
b. Ohio Department of Mental Health
30 East Broad Street
Columbus, Ohio 614-466-2333
c. Ohio Legal Rights Service
8 East Long Street
Columbus, Ohio 1-800-282-9181
d. United States Department of Health & Human Services
105 West Adams Street
Chicago, Illinois 312-886-5078
e. Appropriate professional licensing, regulatory associations and/or other
State Departments. The names, addresses, and phone numbers of the aforementioned
will be given to the griever. All relevant information about the grievance will
be forwarded as requested with an appropriate Authorization for Release of
Information form signed by the client or current legal guardian.
4. If the agency Client Rights Advocate and agency Chief Executive Officer
conclude that action is necessary to protect the person served pending
resolution of the grievance, such action shall be taken immediately.
5. The agency Client Rights Advocate shall begin an immediate investigation
regarding the grievance.
6. A written response including an explanation of the agency’s resolution to the
grievance shall be provided to the client and grievant (if other than the
client), including information on the grievant’s right to appeal the agency’s
resolution to the outside entities listed in V-E-3.
E. The grievant may give permission to extend the twenty
working days for the resolution.
VI. CHILD AND ADOLESCENT SERVICE CENTER POLICY
In addition to the Client Rights, Child and Adolescent Service Center shall
observe the following:
A. All individualized service/treatment plans are reviewed according to Quality
Assurance standards.
B. All policies and procedures affecting treatment will be explained to the
individual/family/guardian in a language that the
individual/family/guardian can understand.
C. Any individual with a hearing impairment will be provided
with an interpreter and other auxiliary aids when necessary to afford such
person an equal opportunity to benefit from services, at no cost to the
individual. If such assistance or aids are necessary, the client/guardian shall
inform CASC staff. (Refer to OL 07.14 Clients with Sensory Impairment.)
D. Each client/family/guardian shall be provided information
regarding the expectation, responsibilities and privileges of the client.
E. Each client/family/guardian shall be provided information regarding rules of
the program and consequences for breaking these rules.
F. With consent, referral source(s) may be notified of an
individual’s termination or suspension from treatment (i.e. Department of Jobs
and Family Services, criminal justice authority, school.)
G. The individual/family/guardian has a right to request a change
of service provider.
H. The individual/family/guardian has a right to support from an
adult advocate who will express and pursue the wishes of the child or
adolescent, and who will employ procedural safe-guards when fundamental rights
and interests are threatened.
I. All CASC employees shall act in accordance with the law to
protect individuals from abusive, neglectful and endangering
situations.
J. Appropriate local, state, and federal regulations pertaining to
nondiscrimination shall be posted where visible to clients and public.
K. In case of emergency, clients/parent/guardians will at the least be
informed of their rights to accept or reject any service.
VII. ACCESS TO RECORDS
A. All CASC clients/guardians have the following rights
with regard to access of clinical records:
1. The right to receive written clinical information included in the designated
record set following a completed authorization to release information signed by
the current legal guardian. The request will be responded to within ten working
days. Information in the record from other sources may be released only with an
appropriate specific release of information form signed by the legal guardian.
2. the right to have no written clinical information released to any outside
party unless written authorization is given by the legal guardian or mandated by
law.
3. the right to challenge information in their child’s clinical record and to
request an unbiased investigation of the accuracy of the information in
question. The client/guardian may insert a statement of clarification or
amendment in the client’s clinical record.
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