The Fairfield County Alcohol, Drug Addiction, & Mental Health Board understands that medical information about you and your health is personal. We are committed to protecting and safeguarding that information against unauthorized use or disclosure. We are required by law to assure, medical information that identifies you is kept private; give you Notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the Notice that is currently in effect. This Notice applies to all records we have related to your care.

WHY WE COLLECT MEDICAL INFORMATION
We collect personal information to determine eligibility for health care coverage; provide benefits and pay claims; conduct service evaluation of programs; and provide other information for planning and improving mental health and substance abuse services in the community. We may also be required to collect and keep certain information so that we meet legal and regulatory requirements; and we keep it after the health care coverage ends.

TYPES OF INFORMATION WE COLLECT
You are asked to complete an enrollment form when seeking benefits that includes information such as: name, address, phone, date of birth, marital status, social security number, and family income. We may also receive information about you from others, such as doctors, clinics hospitals and other health care providers; other Alcohol, Drug Addiction and/or Mental Health (ADAMH) Boards that provide coverage to our clients or assist our board with its administrative functions; business partners that provide us with products and services; and other government agencies such as the criminal justice system, child welfare and juvenile justice. The information we collect from others may include for example, eligibility, claims and payment information. We create and maintain a record of your enrollment in the public mental health and or drug addiction and substance abuse system of the State of Ohio, and maintain records of payment for treatment you receive in the public system. From time to time we may also receive information from your treatment provider related to your diagnosis, treatment and progress in recovery, and any major unexpected emergencies or crises you may experience that help the Board plan for and improve the quality of services for the region's citizens.

SAFEGUARDING YOUR PERSONAL INFORMATION
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 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 Board maintains policies and procedures that prohibit employees and agents of the 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.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
We use and disclose Protected Health information (PHI) for a variety of reasons. We have limited right to use and/or disclose your PHI for purposes of treatment, payment and for our health care opertions. For uses beyond that, we must have your writen authorization unless the law permits or requires us to make the use or disclosure withour your authorization. If we disclose your PHI to an outside entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures withou your consent or authorization. The following describes and offers some examples of our potential uses/disclosures of your PHI.
For treatment: We may disclose your PHI to doctors, counselors and other hospital and health care personnel who are involved in providing your care. For example, information may be shared to help members of your treatment team (including your doctor, nurse, casemanager, guardian, power of attorney for health care) maximize and coordinate treatment benefits.
For payment: We may use and disclose your PHI to determine eligibility for plan benefits, process and pay your claims and administer your health plan benefits. This may include determining eligibility for co-pay, Medicaid or other sources of payment, reviewing submitted claims and processing payment for those claims to your treatment agency.
For health care operations: We may use and disclose your PHI for required Board operations. For example, we may conduct an audit to evaluate the quality of the services you receive and/or make plans to better serve the community through mental health and alcohol or other drug services.
Business Partners: We may disclose your PHI to a Business Partner in order for that entity to perform a function on our behalf, such as administering benefits and services. We must have in place an agreement from the Business partner that extends the same degree of privacy protection to your information that the Board must apply.
Authorized representatives: This may include parents and guardians, or persons who have legal authority to make health care decisions on your behalf.
Other uses:
For research purposes: For instance, if a waiver of authorization has been obtained in order to assist in medical research.
For Public Health activities: For instance, when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.
Relating to decedents: For instance, information relating to a death to coroners, medical examiners or funeral directors.
As required by law: For instance, when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity.
To avert a serious threat to Health or Safety: For instance, to law enforcement or other persons who can reasonably prevent or lessen the threat of harm to the health or safety of a person or the general public.
For Specific Government Functions: For instance, to military personnel and veterans in certain situations, to correctional facilities, to government benefit programs relating to eligibility and enrollment, for national security reasons, such as protection of the President.
Worker's Compensation: For instance, to comply with the laws relating to worker's compensation or other similar programs.
Lawsuits and Disputes: For instance, in the course of judicial and administrative proceedings.
Law Enforcement and Regulatory authorities: For instance, as required by law in response to a court order.
National Security and Intelligence Activities: For instance, for national security reasons, such as protection of the President. For any other types of disclosures to third parties, we require a client, guardian or a parent of a minor to complete a release of authorization. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.
"OPTING OUT" OF INFORMATION SHARING
You may have received Notices of Privacy Practices from treatment providers or other organizations that allow you to "opt out" of certain disclosures. A common type of disclosure to which "opt outs" apply is the disclosure of personal information at a hospital information desk that allows visitor to know where you are and your general condition. As a health plan, the Fairfield County Alcohol, Drug Addiction, & Mental Health Board must follow many federal and state laws that prohibit us from making these types of disclosures. Because we do not make disclosures to which "opt outs" apply, it is not necessary for you to complete an "opt out" form or take any action to restrict such disclosures.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding health information:
To Request Restrictions: You have a right to request a restriction or limitation on the use and disclosure of your PHI. We will consider your request however, we are not legally bound to agree to the restriction. We cannot agree to limit uses/disclosures that are required by law.
To Choose How We Contact You: You have the right to request confidential communications through a reasonable alternative means or at an alternative location. For instance, you can ask that we only contact you by mail, at work.
To Inspect and Copy: You have a right to inspect and copy your personal information unless the access to your records is restricted for clear and documented treatment reasons. For instance, we may not share information 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 be in writing and we will provide you with a written response within 30 days of your request. If your request is denied, we will also give you a written explanation of the reason for the denial.
To request an amendment: You have a right to request an amendment if you believe there is a mistake or missing information. We will respond within 60 days of receiving your written request. We may deny the request if we determine the information is correct and complete; not created by us and/or not part of our records, or; not permitted to be disclosed. If we approve the request for amendment, we will notify you of the change and inform others that need to know about the change in your information.
To receive an accounting of disclosures: You have a right to request an accounting of the disclosures of your PHI that has been released for purposes other than treatment, payment or health care operations; to you, or pursuant to your written authorization. The list will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, when the information is subject to a lawsuit, is a danger to you or someone else or disclosures made before April 14, 2003.
To receive a paper copy of this notice: You have a right to a paper copy of this Notice by contacting the Board office. This Notice is also available at our web site: www.fair-mh.org
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 medical information we already have about you as well as any information we receive in the future. A copy of the current Notice will be posted at the Board office. 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.
OTHER USES OF PERSONAL HEALTH INFORMATION
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.
COMPLAINTS ABOUT OUR PRIVACY PRACTICES
If you have a complaint about our privacy practices or if you believe your privacy rights have been violated, you may file a complaint with the Board's Privacy Officer at the address below or with the Secretary of the Department of Health and Human Services. We will not retaliate against you in any way for filing a complaint.

Contact Person to Exercise Your Rights, for Additional Information or to Submit a Complaint: Privacy Officer - Fairfield County ADAMH Board, 108 W. Main Street, Lancaster, OH 43130 Phone: 740-654-0829