Notice and Consent Form
A. This Notice of privacy practices describes how we may use and disclose your protected health (PHI) related to the Confidentiality of Program Participant Records to carry out student assistance services, behavioral health treatment, billing or other healthcare operations for the purposes that are permitted or required by federal and state laws.
Federal and State laws protect the use of protected health information and confidentiality of participant records maintained by True North—Student Assistance and Treatment services (the program). Generally, this means that the Program may not disclose to anyone outside the Program that a participant attends the Program or disclose communications between individuals not employed by the program. Under Federal and State law, confidentiality protections do not apply in these circumstances:
Exceptions applicable to all Program participants
- A participant gives written consent to release information to a specific person or agency. (Probation officers will receive only a summary of work done toward goals.)
- A court order that includes special findings requires it.
- The disclosure is made in the course of reporting suspected child abuse or neglect as required by State law.
- When a person is in danger of harming themselves or others the Program may notify school administrators, counselor, parents/guardian, a Mental Health Professional, or law enforcement, as may be appropriate and necessary. This includes suicidal intent or late stage addiction constituting “imminent harm.” Program staff will not disclose that a participant is being seen for substance abuse without written consent.
- The Program Administrator, in the course of carrying out his or her duties to administer the Program and supervise staff.
- The disclosure is made to medical personnel in a medical emergency where disclosure of the diagnosis is necessary to treat the emergency.
- The disclosure is made to qualified personnel for research, audit or program evaluation.
- The disclosure is made in the course of reporting to law enforcement any crime committed by a participant at the Program or against any Program staff, or any threat of such a crime.
For substance abuse programs, federal law prohibits disclosure outside the Program that a participant is being seen in the Program for a substance abuse or disclosure of any information that identifies a participant as a person who has a substance abuse, except for the circumstances described above. Violation of this Federal law and regulation by the Program is a crime. You may report suspected violations to the
appropriate authorities in accordance with Federal regulations. (See Federal laws 42 U.S.C. 290dd-3 and 42 U.S.C 290ee-3 and Federal regulations 42 CFR, Part 2.) In all cases described above, except when written consent is given, the Program Administrator will be consulted before any disclosure is made. In all cases, the recipient of the disclosure will be informed that redisclosure is not permitted without your written consent.
B. Consent for Release of Confidential Information
Because this is a school-based program offered in cooperation with your school district, you are asked to consent to the disclosure of limited information (including your status as a participant in the Program for behavioral health, if applicable) to school administrators and your parents or guardian under the following circumstances:
- The fact that you have complied with a referral to the Program (including completing or dropping out of the program) may be disclosed to a school principal or counselor for the purpose of information them how your needs are being served.
- The date and times of your attendance at the Program may be disclosed to a school principal or attendance officer for the purpose of verifying that you complied with the State school attendance laws and were properly absent from class.
- The fact that you are a participant in the Program may be disclosed to school administrators and your parents or guardians if Program staff are obligated to report a medical emergency in accordance with school district policy and procedures concerning notification of medical emergencies involving students.
- The fact that you are a participant in the Program may be disclosed to school administrators and your parents or guardians if Program staff are obligated to report any violations by you of school district policies, including those concerning the commission of a crime, or threat to commit a crime, on school premises or being on school premises or at school functions under the influence of alcohol or drugs.
- We will use and disclose your protected health information (PHI) to provide, coordinate, or manage health care services for behavioral health or any other related services. This includes the management of your health care with a third party.
- Your protected heath care information will be used, as needed to obtain payment for your health care services provided to you or family member to appropriate billing entities.
You have rights as a program participant. The following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
Anyone receiving information allowed by this Consent will also be given written notice that they may not further disclose the information unless you give written consent.
You may revoke this Consent at any time except to the extent that action has been taken in reliance on it and, in any event, this Consent expires automatically when you are no longer a student in the School District in which you are currently enrolled.
C. I have read the Confidentiality and HIPAA Privacy Practices Notice for Participant Records and the consent for Release of Confidential Information and had them explained to me.
Signature of participant/student Date
Signature of parent/guardian Date
Signature of Program Staff Date