Notice of Privacy Practice

Notice Regarding the Use and Disclosure Of Protected Health Information

Effective July 1, 2013

This notice describes how we, Child and Adolescent Behavioral Health, use or disclose your Protected Health Information (“PHI”). PHI is information that identifies you and relates to health care services, the payment of health care services or your physical or mental health or condition, in the past, present or future. This notice also describes your rights to access and control your PHI.

Our Responsibilities

Federal law requires that we maintain the privacy of your PHI and provide to you with this Notice of our legal duties and privacy practices. We are required to notify affected individuals following a breach of unsecured PHI. We are required to abide by the terms of this Notice, which may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain. We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your rights, our duties, or other practices stated in this Notice. Except when required by law, a material change to this notice will not be implemented before the effective date of the new notice in which the material change is reflected.

How We May Use or Disclose PHI For Treatment, Payment, and Health Care Operations


For Treatment. We may use and disclose your PHI to coordinate or manage your care within Child and Adolescent Behavioral Health and with individuals or organizations outside of Child and Adolescent Behavioral Health that are involved in your care, such as your attending physician, other health care professionals, contracted service providers or related  organizations. For example, certain service providers involved in your care may need information about your medical condition in order for us to deliver services properly and appropriately.

To Obtain or Provide Payment. We may include your PHI in invoices to collect or provide payment to or from third parties for the care you receive through Child and Adolescent Behavioral Health. For example, some PHI is transmitted to the Ohio Department of Aging  and the Ohio Department of Job and Family Services when billing transactions are conducted. To Conduct Health Care Operations. We may use and disclose PHI for our own operations and as necessary to provide quality care to all of our service recipients. Health care operations includes but is not limited to the following activities: quality assessment and improvement activities; activities designed to improve health or reduce health care costs; protocol development, case management and care coordination; professional review and performance evaluation; review and auditing, including compliance reviews, medical reviews, legal services and compliance programs; and business management and general administrative activities of Child and Adolescent Behavioral Health. For example, we may use PHI to evaluate our staff performance or combine your health information with other consumer PHI to evaluate how to better serve all of our consumers. Another example may be the disclosure of your PHI to staff or contracted personnel for certain limited training purposes.

How We May Use or Disclose PHI For Appointment Reminders, Treatment Alternatives, or Fundraising Activities


We may use and disclose your PHI to contact you as a reminder that you have an appointment for a home visit. We may use and disclose your PHI to advise you or recommend possible service options or alternatives that may be of interest to you. We may contact you for fund- raising activities. However, you will be provided the opportunity to opt out of receiving such fundraising communications.

Disclosures You May Authorize Us to Make

We will not use or disclose your PHI without authorization, except as described in this Notice. Most uses and disclosures of psychotherapy notes, as applicable, require your authorization. Subject to certain limited exceptions, we may not use or disclose PHI for marketing without your authorization. We may not sell PHI without your authorization. You may give us written authorization to use and/or disclose health information to anyone for any purpose. If you authorize us to use or disclose such information, you may revoke that authorization in writing at any time.

Other Specific Uses or Disclosures

When Legally Required. We will disclose your PHI when required by any Federal, State or local law.

In the Event of a Serious Threat To Life, Health Or Safety. We may, consistent with applicable law and ethical standards of conduct, disclose your PHI if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to your life, health, or safety, or to the health and safety of the public.

When There Are Risks to Public Health. Child and Adolescent Behavioral Health may disclose your PHI for public activities and purposes allowed by law in order to prevent or control disease, injury or disability; report disease, injury, and vital events such as birth or death; conduct public health surveillance, investigations, and interventions; or Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To Report Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe a consumer is the victim of abuse, neglect or domestic violence. We will make this disclosure only when required or authorized by law, or when the consumer agrees to the disclosure.

To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. However, we may not disclose your PHI if you  are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order, or, in response to a subpoena, discovery request or other lawful process, if we determine that reasonable efforts have been made by the party seeking the information to either notify you about the request or to secure a qualified protective order regarding your health information. Under Ohio law, some requests may require a court order for the release of any confidential medical information.

For Law Enforcement Purposes. As permitted or required by law, we may disclose specific and limited PHI about you for certain law enforcement purposes.

For Research Purposes. We may, under very select circumstances, use your PHI for research. Before we disclose any of your PHI for such research purposes in a way that you could be identified, the project will be subject to an extensive review and approval process, unless otherwise prohibited as with Medicaid.

For Specified Government Functions. Federal regulations may require or authorize us to use or disclose your PHI to facilitate specified government functions relating to military and veterans; national security and intelligence activities; protective services for the President and others; medical suitability determinations; and inmates and law enforcement custody.

For Workers’ Compensation. We may use or disclose your PHI for workers’ compensation or similar programs.

Transfer of Information at Death. In certain circumstances, we may disclose your PHI to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.

Organ Procurement Organizations. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purposes of tissue donation and transplant.

Your Rights with Respect to PHI 

You have the following rights regarding PHI that we maintain:

Right to a Personal Representative. You may identify persons to us who may serve as your authorized personal representative, such as a court-appointed guardian, a properly executed and specific power-of-attorney granting such authority, a Durable Power of  Attorney  for Health Care if it allows such person to act when you are able to communicate on your own, or other method recognized by applicable law. We may, however, reject a representative if, in our professional judgment, we determine that it is not in your best interest.

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on our disclosure of your PHI to someone who is involved in your care or the payment of your care. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it unless the request concerns a disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full. To request such restrictions, please contact your C&A (Child and Adolescent Behavioral Health) provider or Privacy Official at 330-433-6075.

Right to Receive Confidential Communications. You have the right to request that we communicate with you in a confidential manner. For example, you may ask us to conduct communications pertaining to your health information only with you privately, with no other family members present. If you wish to receive confidential communications, please contact your C&A or Privacy Official at 330-433-6075. We may not require that you provide an explanation for your request and will attempt to honor any reasonable requests.

Right to Inspect and Copy Your PHI. Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your PHI upon request. You have the right to inspect and copy such health information, including billing records, at a reasonable time and place. A request to inspect and copy records containing your PHI may be made to your C&A provider or Privacy Official at 330-433-6075. If you request a copy of such health information, we may charge reasonable copying, processing, and personnel fees.

Right to Amend Your PHI. You have the right to request that we amend your records, if you believe that your PHI is incorrect or incomplete. That request may be made as long as we maintain the information. A request for an amendment of records must be made in writing to your C&A provider or Privacy Official at Child and Adolescent Behavioral Health, 4641 Fulton Dr. N.W., Canton, Ohio, 44718. We may deny the request if it is not in writing, or does not include a reason for the amendment. The request also may be denied if your health information records were not created by us, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of the health information you  are permitted to inspect and copy, or if, in our opinion, the records containing your health information are accurate and complete. We take the position that amendments may take the form of including a written statement from you and may not include changing, defacing or destroying any necessary information related to your health care.

Right to Know What Disclosures Have Been Made. You have the right to request an accounting of disclosures of your PHI made by us for certain reasons, including reasons related to public purposes authorized by law, and certain research. The request for an accounting must be made in writing to your C&A provider or Privacy Official at Child and Adolescent Behavioral Health, 919 2nd Street NE, Canton, Ohio 44704. The request must specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years prior to the date on which the accounting is requested. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable, cost-based  fee.

Right to a Paper Copy of This Notice. You have a right to receive paper copy of this Notice at any time, even if you have received this Notice previously. To obtain a paper copy, please contact your C&A provider or Privacy Official at 330-433-6075.

Where to File a Complaint

You have the right to complain to us if you believe that your privacy rights have been violated, including the denial of any rights set forth in this Notice. Any complaints to us shall be made  in writing to your C&A provider or the Privacy Official at Child and Adolescent Behavioral Health, 4641 Fulton Dr. N.W., Canton, Ohio 44718. We encourage you to express any concerns  you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 20201 or call toll-free (877) 696-6775, by e-mail to OCRComplaint @ hhs.gov, or to Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312) 886-1807, or TDD (312) 353-5693.

Contact Persons 

We have designated the Privacy Official as our contact point for all issues regarding consumer privacy and your rights under this Notice. If you have any questions regarding this Notice, please contact your C&A provider or Privacy Official at 330-433-6075 x 207.

Effective Date

This Notice is effective July 1, 2013.

If You Have Any Questions Regarding This Notice, please contact your C&A provider or Privacy Official at 330-433-6075.




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 Behavioral Health 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.

    1. “Client” means an individual applying for or receiving mental health services .
    2. “Client Rights Officer” means the individual designated by a mental health agency with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within the agency.
    3. “Contract Agency” means a public or private service provider with which community mental health board enters into a contract for the delivery of mental health
    4. “Grievance” means a written complaint initiated either verbally or in writing by a client or by any other person or agency on behalf of a client regarding denial or abuse of any client’s
    5. “Reasonable” means a standard for what is fair and appropriate under usual and ordinary“Services” means the complete array of professional interventions designed to help a person achieve improvements in mental health such as counseling, individual or group therapy, education, community psychiatric supportive treatment, assessment, diagnosis, treatment planning and goal setting, clinical review, psychopharmacology, discharge planning,  professionally-led support,
    1. The right to be informed of the rights described in this rule prior to consent to proceed with services, and the right to request a written copy of these rights;
    2. the right to receive information in language and terms appropriate for the person’s understanding;
    3. the right to be fully informed of the cost of services;
    4. the right to be treated with consideration, respect for personal dignity, autonomy, and privacy, and within the parameters of relevant sections of the Ohio Revised Code and the Ohio Administrative Code;
    5. the right to receive humane services;
    6. the right to participate  in  any  appropriate and available  service  that is consistent with an individual service/treatment plan, regardless of the refusal of  any  other  service,  unless that service is a necessity  for clear  treatment reasons and requires the person's participation;
    7. the right to reasonable assistance, in the least restrictive setting;
    8. the right to reasonable protection from physical, sexual and emotional abuse, inhumane treatment, assault, or battery by any other
    9. the right to a  current ISP that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, as available, either directly or by referral;
    10. the right to actively participate in periodic ISP reviews with the staff including services necessary upon discharge;
    11. the right to give full informed consent to any service including medica- tion prior to commencement and the right to decline services including medication absent an emergency;
    12. the right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies, or photographs, or  other  audio  and visual technology. This right does not prohibit an agency from using closed-circuit  monitoring  to observe seclusion rooms or common areas, which does not include bathrooms;
    13. the right to decline any hazardous procedures;
    14. the right to be free from restraint or seclusion unless there is imminent risk of physical harm to self or others;
    15. the right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non agency surveyors, contractors, construction crews or others.
    16. the right to confidentiality unless a release or exchange of information is authorized and the right to request to restrict treatment information being shared;
    17. the right to be informed of the circumstances under which an agency is authorized or intends to release, or has released, confidential information without written consent for the purposes of continuity of care as permitted by division (A)(7)  of  section  31  of  the Revised Code.
    18. the right to have the grievance procedure explained orally and in writing; the right to file a grievance with assistance if  requested; and the right to have a grievance reviewed through the grievance process, including the right to appeal
    19. the right to receive services free of discrimination on the  basis  of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws;
    20. the right to exercise rights without reprisal in any form including the ability to continue services with uncompromised access. No right extends so far as to supersede health and safety considerations;
    21. the right to have the opportunity to consult with independent specialists or legal counsel at one's own expense;
    22. the right to have no conflict of  interest – i.e. no agency employee may be a person's guardian or representative if the person is currently receiving services from said facility;
    23. 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 treatment plan. If access is restricted, the treatment plan shall also include a goal to remove the restriction;
    24. the right to  be  informed in  advance of  the  reason(s) for  discontinuance  of service provision, and to be involved  in  planning for the consequences  of that event;
    25. the right to receive an explanation of the reasons for denial of
    1. The grievance procedure  shall  be  posted  in  a  highly visible place in each agency
    2. Upon request, all Child and Adolescent Behavioral Health (C&A) clients and/or guardians shall be provided with oral and written instructions for filing a grievance. Any C&A client/guardian who has a concern, complaint, or grievance should contact Client Rights Officer, Kim Cernansky, at Child and Adolescent  Behavioral  Health, 4641 Fulton Dr. N.W., Canton, Ohio 44718, 330-433-6075 x207, or Alternate Client Rights Officer, David Coleman, 330-433-6075 x 208. Business hours are Monday-Friday 8:00 a.m. - 5:00pm
    3. C&A 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 Officer is  the subject of the
    4. Any person (client/family/other) who has a concern, complaint or grievance shall immediately be provided with the name and phone number of the agency Client Rights Officer (Kim Cernansky, 330-823-5335). The Client Rights Officer and/or Alternate CRO (Colin Christensen, 330-433-6075 x 207) will assist the griever in resolving the concern through the following steps:
    5. C&A clients/guardians shall attempt to discuss any concerns with the source of that
    6. If the C&A client/guardian is not satisfied, he/she will contact and/or meet with the immediate supervisor/designee within two(2) working days. The supervisor may also meet with the supervisee. The Chief Executive Officer and the Client Rights Officer shall be notified of the concern.
    7. If the C&A client’s concerns remain unresolved, the client/guardian shall meet with the appropriate Administrator/ Department Head/designee, within two (2) working
      1. Immediately following the client’s meeting with the Administrator/Department Head/designee, the Client Rights Officer/designee shall meet with the client and with the Administrator/Department Head/designee to (a) ascertain that a resolution has been reached or (b) if no resolution has occurred, to determine what concerns still exist and to attempt to resolve those concerns.
    8. If the C&A client’s/guardian’s concerns still remain unresolved, the Client Rights Officer/designee  shall  assist  the client/guardian in preparing and submitting a written statement to the Chief Executive Officer  within  three  (3) working days.
    9. The Chief Executive Officer, as an impartial decision-maker, shall meet with the client/guardian and then shall confer with the Chief Operating   Officer and Client Rights Officer as part of the
    10. Within three (3) working days, the Chief Executive Officer will convey his decision, in writing, to the client/guardian.
    11. If the C&A client/guardian is still not satisfied, he/she may address an Ad Hoc Committee composed of a member of the Board of Trustees, the Chief Executive Officer, the Client Rights Officer,   and  an  impartial   agency The Committee will meet and deliver a decision with ten (10) working days.
    12. After each attempt to resolve the client’s grievance, the Client Rights Officer/designee will give the client written notification and an explanation of the
    13. Upon written request of the client, information may be released regarding the
    14. All C&A   clients/guardians   shall   be   provided   the opportunity to file a grievance within a reasonable period of time or as mandated mandated by law (particularly in the case of children), from the date  the grievance occurred and a time line not exceed twenty (20) working days from the date of filing the grievance until a resolution of the grievance within this
    15. All C&A clients/guardians shall have the option to register a complaint with any or all, but not exclusively, the following:
      1. Stark County Mental Health and Addiction Recovery Services Board 121 Cleveland Ave. N.W., Canton, OH 44702 Telephone: 330-455-6644; Fax: 330-455-4242.
      2. Ohio Mental Health and Addiction Services 30 East Broad Street, Columbus, OH 43215 Telephone: 614-466-2333
      3. Disability Rights Ohio 50 West Broad Street, Columbus, OH 43215 Telephone: 800-282-9181
    16. S. Dept. of Health and Human Services, Regional Office 233 N. Michigan Avenue, Chicago, IL 60601 Telephone: 312-886-2359
    17. Appropriate professional licensing, regulatory associations and/or other State

The names, addresses, and phone numbers of the afore- mentioned  will  be given to the griever.

    1. In addition to the Client Rights, Child and Adolescent Behavioral Health shall observe the following:
      1. All individualized  service/treatment   plans  are  reviewed  according to Quality Assurance
      2. All policies and procedures affecting treatment  will  be explained to the individual/family/guardian in a language that the individual/family/ guardian can
      3. 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 C&A staff. (Refer to OL 07.14 Clients with Sensory )
      4. Any client/family/guardian whose primary language is not standard English will be provided with an interpreter at the agency’s Some documents are available in Spanish.
      5. Each client/family/guardian shall be provided information regarding the expectation, responsibilities and privileges of the
      6. Each client/family/guardian shall be provided information regarding rules of the program and consequences for breaking these
      7. With authorization, 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.)
      8. The individual/family/guardian has a right to request a change of service
      9. 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
      10. All C&A employees shall act in accordance with the law to protect individuals from abusive, neglectful and endangering situations.
      11. Appropriate local, state, and federal regulations pertaining to nondiscrimination shall be posted where visible to clients and
      12. In case of emergency, clients/parent/guardians will at the least be informed of their rights to accept or reject any
    1. All C&A clients and/or current 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 (10) working days, if possible. Information in the record from other sources may be released only with an appropriate specific release of information form signed by the legal
      2. the right to have no written clinical information released to any outside party unless written authorization is given by the client or legal guardian or mandated by law; and
      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 request to insert a statement of clarification or amendment in the client’s clinical