ADDICTION SPECIALISTS OF KANSAS, INC. ("ASK")
Notice of Privacy Practices for Protected Health Information
This Notice describes your rights and certain obligations ASK has regarding the use and disclosure of health information. It also tells you about the ways in which ASK may use and disclose health information about you.
PLEASE READ CAREFULLY!

ASK is required by law to maintain the privacy of your health information. With your written consent, ASK is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. ASK is obligated to follow the terms of the notice that is currently in effect.

Examples of uses of your health information for treatment purposes are:

• A staff member obtains assessment/treatment information about you and records it in your record/chart.
  
  
• During the course of your treatment, the physician or counselor determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.

An example of use of your health information for payment purposes:

• We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding care given. We will provide information to them about you and the care given.

An example of use of your health information for health care operations:

• The state licensing authority wants to review records to assure that we have acted consistent with state law regarding your care. In doing so, it wants to take a sampling, which includes review of your chart. At the licensing authority's request, we will provide it with a copy of your record.

Your Health Information Rights

The health record we maintain and billing records are the physical property of ASK. The information in it, however, belongs to you. You have a right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office-we are not required to grant the request but we will comply with any request granted;
  
  
• Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;
  
  
• Request that you be allowed to inspect and copy your health record and billing record-you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request;
  
  
• Appeal a denial of access to your protected health information except in certain circumstances;
  
  
• Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request;
  
  
• File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
  
  
• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give you upon request; and,
  
  
• Revoke authorizations that you made previously to use or disclose information, except to the extent information or action has already been taken, by delivering a written revocation to our office.

You have a right to review the Notice before signing the consent authorizing use and disclosure of you protected health information for treatment, payment, and health care operations purposes.

If you want to exercise any of the above rights, please contact Anne Dolan, Privacy Officer, 650 N. Carriage Parkway, Suite 135, Wichita, KS 67208, 316-685-4700, in person or in writing during normal hours. She will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

ASK is required to:

• Maintain the privacy of your health information as required by law;
  
  
• Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
  
  
• Abide by the terms of the Notice;
  
  
• Notify you if we cannot accommodate a requested restriction or request; and,
  
  
• Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.

Effective 11/1/02, rev. 1/27/03

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Anne Dolan, Privacy Officer, at 316-685-4700.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Anne Dolan. You may also file a complaint by mailing it to the Secretary of Health and Human Services whose street address is 200 Independence Ave. S.W., Washington, D.C. 20201 and website address is www.hhs.gov.

• We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from ASK.
  
  
• We cannot and will not retaliate against you for filing a complaint with the Secretary.

Other Disclosures and Uses

Business associates

• We have business associates with whom we may share your protected health information. For example, in preparing our annual financial statement, auditors may need to review samples of the medical care given. We may disclose your health information to the accounting firm to prepare this material.

Research

• We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Marketing

• We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA)

• We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

• If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

• As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect

• We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

• If you are an inmate of a correctional institution, we may disclose to the institution or agents there of your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

• We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight

• Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

• We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
  
  
• To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions

• We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance personnel.

Other Uses

• Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website

• We maintain a website that provides information about our entity. This Notice is on the website at www.ask-pa.com.

Effective 11/1/02, rev. 1/27/03