Model Part 2 Patient Notice

Your Information. Your Rights. Our Responsibilities.

Notice of Privacy Practices of [Name of Part 2 Program]

This notice describes:

  • HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
  • YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
  • HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION
  • YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH [ENTER NAME OR TITLE] AT [PHONE AND EMAIL] IF YOU HAVE ANY QUESTIONS.

In this notice, your health information means your substance use disorder patient record.

Your Rights

You have the right to:

  • Consent to most uses and disclosures of your health information
  • Ask us to limit the information we share
  • Get a copy of this privacy notice
  • Discuss this notice with someone in our program
  • Get a list of those with whom we’ve shared your electronic records*
  • Get a list of health care providers who have received your information through certain third parties
  • Choose in advance whether to receive fundraising communications
  • File a complaint if you believe your privacy rights have been violated

Your Choices

With your consent, we can use and share your information as we:

  • Treat you
  • Run our organization
  • Bill for our services
  • Fulfill your requests to share information with your consent
  • Prevent multiple program enrollments
  • Report about court-referred treatment
  • Report to prescription drug monitoring programs

Our Uses and Disclosures

We may use and share your information without your consent as we:

  • Communicate within our program and with our contractors
  • Help with medical emergencies
  • Help with public health
  • Report crimes (and threats of crimes) on our premises and suspected child abuse and neglect
  • Aid scientific research
  • Respond to audits and evaluations of our program
  • Assist cause of death inquiries
  • Respond to court orders

In all these circumstances, we must protect your information and limit how we use and share it.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Provide consent when we use or share your information for most purposes

  • You may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes.
  • [SUGGESTED OPTIONAL LANGUAGE: You may provide consent for more limited purposes (for example, to only disclose information to another health care provider for your treatment); however, doing so may affect the services we can provide you or how you pay for services.]
  • [SUGGESTED OPTIONAL LANGUAGE: You may provide a general consent to share your information through certain third parties, such as a health information network or a research institution, where your treating health care providers can access it.]

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our health care operations after you have provided consent for all those purposes. We are not required to agree to your request, and we may say “no” if, for example, it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our health care operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Discuss this notice with someone in our program

You can ask questions or obtain more information about this notice and our privacy practices by calling or emailing the contact person at the top of this notice.

Choose in advance about fundraising

You have the right to a clear and obvious notice in advance of, and a choice about whether to receive, fundraising communications for our program.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services’ Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
  • We will not retaliate against you for filing a complaint.

Your Choices

How do we typically use or share your health information?

With your consent, we typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for a chronic condition asks a doctor at our program about your health condition and medications you are taking, for example, to avoid complications.

Run our organization

We can use and share your health information to run our program, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

With your consent, we may also use and share your information in the following ways:

  • To whomever you name in a consent to share your information
  • To prevent multiple enrollments in withdrawal management or maintenance treatment programs
  • To report participation in treatment required by the criminal justice system
  • To report prescribed substance use disorder treatment medications to a state prescription drug monitoring program when required by law

You can choose someone to act for you.

  • If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

Our Uses and Disclosures

How else can we use or share your health information?

We are allowed or required to share your information in certain ways without your consent – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

To communicate within our program and with contractors

We can share your information within our program, with an organization that has administrative control over our program, and with contractors who help us run our program.

For medical emergencies

We can share your information during a bona fide medical emergency with the personnel and health care providers responding to your emergency, even when you are unable to consent because of the emergency.

We can also share your identifying information to assist the federal Food and Drug Administration in notifying you or your doctor about unsafe products you may be using.

Help with public health

We can share health information that does not identify you for certain situations such as:

  • Preventing disease
  • Reporting adverse reactions to medications

Aid scientific research

We can use or share your information to conduct or help with health research. Researchers cannot include any patient identifying information in their reports about the research.

Respond to management and financial audits and program evaluations

We can use or share your information to improve the quality of our services, obtain needed credentials, and cooperate with oversight agencies for activities authorized by law, as long as those who view or receive the information agree to destroy or return the information when they are finished and agree not to use it against you.

Assist with cause of death inquiries

We can share patient identifying information about a deceased patient as required or allowed by laws that collect information relating to cause of death.

Report suspected child abuse and neglect

We will only report the information required by law.

Prevent or reduce crime in our program

We may report to law enforcement when a patient commits or threatens to commit a crime within our program or against our staff.

Redisclosure According to HIPAA

When you consent to uses and disclosures for all future treatment and payment purposes and to run our business, we may share your information with other substance use disorder treatment programs, doctors’ offices, and health care businesses for those activities. If the person who receives it is subject to HIPAA, then they are allowed to use and share your information again without your consent for the purposes that HIPAA allows. Your information still cannot be used in legal proceedings against you unless (1) you consent or (2) based on a Part 2 court order and a subpoena (or similar legal requirement).

Legal Proceedings and Court Orders

We must follow certain procedures before using or sharing your information for investigations and legal proceedings.

  • We will not use or share your information or provide testimony about your information in any civil, administrative, criminal, or legislative proceedings against you without your written consent or a court order.
  • We will only respond to a court order to use or share your health information if it is accompanied by a subpoena or other similar legal mandate requiring us to comply.
  • We will only use or share your information in proceedings against you based on a court order after we have received notice and an opportunity to be heard or you tell us that you have received notice.
  • We may use or share your information to respond to legal proceedings against our program based on a court order and you may not be notified in advance. You have the right to seek to overturn or change the court order after you learn about it.

Our Responsibilities

  • We are required to obtain your consent for most uses and sharing of your information.
  • We are required by law to maintain the privacy and security of your information.
  • We must let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice

We are required to follow the terms of this notice that are currently in effect.  We can change the terms of this notice, and the changes will apply to all information we have about you.  The new notice will be available upon request in our office and on our web site.

Effective Date

This notice is effective as of [insert effective date of this notice].

Other Instructions for Notice

  • Insert name or title of the privacy contact and his/her email address and phone number.
  • Insert any special notes that apply to your entity’s practices such as, “We will provide you with a summary of your treatment history upon request.”

Part 2 requires you to describe any state or other laws that require greater limits on disclosures. For example, “The information we can share about you for treatment is limited to admission forms, treatment/discharge forms, and discharge summaries.” Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.

Endnotes

*   The compliance date for this requirement will be set when the same right is revised in the HIPAA Privacy Rule.

Content created by Office for Civil Rights (OCR)
Content last reviewed