Notice of Privacy Rights PDF (English)

Notice of Privacy Rights - Nota De Practicas de Privacidad (Spanish PDF)

Patient - Staff Agreement

I.        INTRODUCTION                       

When you ask for services from us you are forming a relationship with your counselor and the staff of this agency.  This is true whether you come voluntarily or have been sent here.  As members of this organization we are working with certain beliefs and rules about our work with you.

We believe in the individuality and dignity of all patients and staff members.  In line with that belief, we understand that the effort to be alcohol and/or drug free can only be your choice.  Our primary concern is the effect that substance abuse has on your life and the lives of others.  Staff members are here to assist you in making your choice.

You have the right to be told the name, title, and role of the staff member directly responsible for your care and treatment; and to expect the facility to be operated by competent staff members.

You have the right to refuse treatment except in emergencies when dangerous to yourself or others.

You have the right to be free of and protected from any physical, mental, or sexual abuse.

II.  DISCRIMINATION

The Director and members of the staff will treat persons equally regardless of sex, marital status, gender, race, religion, national origin, handicap or sexual preference.  Anyone who believes he or she has been discriminated against may use the complaint procedure.

III.  COMPLAINT PROCEDURE

If you are unhappy with something that is occurring in treatment or within the program and are unable to work it out with your counselor, you have the right to present your complaint in writing to the counselor's supervisor.  If the difficulty cannot be resolved at this level, your complaint will then be reviewed by the Clinical Director, the Director of Worcester County Addictions/Mental Health Programs, and if necessary, by the Health Officer for Worcester County.  If the problem is still not resolved, you have the right to appeal to the local Human Relations Council or the appropriate State or Federal Civil Rights Office.  You may also contact the Joint Commission of Accreditation for Health Organizations at 1-800-994-6610.

IV.  CONFIDENTIALITY

The confidentiality of patient records kept by this agency is protected by Federal and State law and HIPAA regulations.  Violation of Federal and State confidentiality and and/or HIPAA regulations is a crime and can be reported to appropriate authorities.

Generally, the agency cannot disclose any information identifying you unless:

• You consent in writing.
• The disclosure is court ordered.
• The disclosure is made to medical and/or law enforcement personnel in a medical emergency (for example, heart attack, suicidal or homicidal threat or risk.)
• The disclosure is made to qualified personnel who are also governed by the same Federal and State confidentiality regulations, for research, audit, or program evaluation purposes.
• You commit a crime either at the program or against a person who works for the program or you threaten to commit such a crime.

A staff member has reason to believe a child has been subjected to abuse (physical injury) or neglect (mental harm).  In accordance with State and Federal laws, we are required to report the suspected abuse or neglect to State or local authorities.  Recent laws regarding reporting of child abuse now require that this agency:

• Must report child abuse or neglect to the Department of Social Services or law enforcement agency, when we have reason to believe it has occurred, even if the alleged victim is an adult when this information comes to light.
• Must report the above even if the alleged abuser is now deceased.

Cases will be discussed and reviewed within the Health Department.  In these instances, case consultation will be     handled discretely and consideration of the confidentiality laws.  If you are served by several programs within the Health Department, we will respect your rights to privacy and only discuss what is professionally appropriate to     coordinate your care.

You have the right to review the record the program keeps concerning your treatment with this agency.  The record is the property of the Worcester County Health Department.  In order to review the record, the presence of a clinical staff person is required at all times.  The agency has the right to purge medical and psychiatric information from the record before it is reviewed if it is received from any other agency or if, in the judgment of the program, its contents are too sensitive to be understood by an individual untrained in clinical issues.  You have the right to correct any errors in your record.  You will be asked to sign a form for this request.

You may be asked to give your consent to having your picture taken upon entering treatment and upon completion of treatment.  These pictures serve to identify you to the clinical staff and to measure your progress since beginning treatment.  You may claim these pictures at any time during treatment or upon discharge.

You may also be asked to give your consent to be videotaped or audio taped for the purpose of clinical supervision and improvement of your treatment experience.  The video will be erased within two weeks and will not be reviewed by anyone other than clinical staff.  The sole purpose of taping a therapy session is to improve the quality of services rendered by the Addictions/Mental Health Programs and will not be used in any punitive manner.  You have the option of reviewing this tape with your counselor and/or supervisor if you desire to do so.

Pictures and videos are protected by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of alcohol and drug abuse patient records.

V.  BEHAVIOR

This is a public agency whose employees serve the interests and observe the rights of many people.  Therefore, assault, violence, vandalism, and disruptive behavior may result in dismissal from the program.  The possession or use of illegal drugs or alcohol on the premises cannot be allowed because it jeopardizes other patients, staff, and the program itself.  We ask that you be considerate of others' need for privacy and confidentiality.  Illegal behavior is taken very seriously and may lead to a report being filed to the Police Department and may result in prosecution.

VI.  TREATMENT PLAN

The treatment plan lists your treatment goals and the steps toward meeting those goals.  It is flexible and grows with you as you move through your counseling experience.  You will be asked to work with your counselor to design a written treatment plan, which is revised periodically, and presented to you for your signature and dating.

VII.  URINALYSIS

Urinalysis is a tool which assists you and your counselor in monitoring your progress toward abstinence from illegal drugs and alcohol.  We urge you to use this as a self-monitoring tool, which helps you remain honest about your progress in treatment. 

In some cases, we will ask you to provide urine samples, due to court orders, or conditions placed by your employer or Health Insurance Company.

No one is discharged from treatment solely for positive urinalysis results.  This does mean we need to look at revising your treatment plan to include additional structure or more intensive treatment.  Please use the tools available to you.

VIII.  FEES

The person seeking counseling is assessed for ability to pay for services, both for intake and subsequent sessions.  A sliding fee scale is used.  No patient is refused services solely due to the inability to pay.  If a patient is able to, but refuses to pay, the account will be forwarded to Central Collections after 90 days.  The fee may be deducted from any Maryland tax return, if necessary.  Medical assistance and health insurance may cover costs.  Certain insurance companies will not cover treatment except in an approved program; in these situations, it is recommended you contact your insurance company or primary care provider for referral to their approved facilities.    If you have Health Choice, you may refer yourself for substance abuse treatment.  The full fee is charged if insurance is available and not used.  Fees are payable at the time services are received.  Unpaid balances will be billed once monthly and three times following discharge. Our staff will help set up a schedule to assist you in paying an outstanding balance.   If still unpaid, they will be forwarded to the Maryland State Central Collection Unit as appropriate at which time an additional service charge will be added to the unpaid balance.  Certain services are not billed due to State regulations.

IX.  LATENESS AND CANCELLATIONS

It is the responsibility of the counselor and the patient to inform the other if an appointment cannot be kept.  If you are unable to keep an appointment, it is very important that you call as soon as possible to inform your counselor.  This will allow your counselor to try to fill your appointment time with another patient and allow the time to be used productively.  The counselor will extend you the same courtesy if he or she is unable to keep the appointment.  In the event of bad weather, the Worcester County Health Department uses local radio and television for broadcast of closure to patients.

X.  THERAPEUTIC DISCHARGE

If this program determines that you are choosing not to constructively participate in counseling, the consequences may nclude termination of treatment with this clinic.

XI.  AFTERCARE/OUTCOME STUDIES

Aftercare consists of an agreement to stay in contact with your counselor a minimum of once per month for one year after successfully completing your counseling.  Aftercare has been established to help you move comfortably from guided treatment into supported independent recovery.  You have the right to refuse aftercare.

The Worcester County Health Department is required to submit information to its funding sources on client outcomes.  It is important for the continuation of funding that we are able to report on client outcomes after leaving our treatment program.  For this reason, you will be asked to allow us to contact you at certain points after you have completed treatment.  This will allow our program to report outcomes to our funding source.  We never identify individual clients in these reports, only the overall results.  Please ask your counselor for further information.

XII.  CLIENT CONFIRMATION

My signature below confirms that I have received a copy of the Worcester County Addiction and Mental Health Programs Patient-Staff Agreement today.  This includes a summary of the Federal law and regulations regarding confidentiality of addiction and mental health client records.  These have been reviewed with me today, I understand their meaning and agree to the conditions of treatment.