SUNRISE BEHAVIORAL HEALTH AND SUPPORT SERVICES
Privacy Practices Notice
NOTICE OF PRIVACY PRACTICES
SUMMARY OF NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.
Sunrise Behavioral Health and Support Services will not disclose any information identifying an individual as being a client
or provide any behavioral health or medical information relating to a client’s treatment unless: (a) there is written consent
from the client or legal representative (parent/guardian), (b) a court order requires disclosure of the information, (c)
medical personnel need the information to meet a medical emergency, (d) qualified personnel use the information for the
purposes of payment, treatment, healthcare operations, conducting research, management audits or program evaluations,
or (e) it is necessary to report a crime or threat to commit a crime or to report abuse or neglect as required by law. Your
authorization is required for all other disclosures of protected health information.
Under the law, each patient has certain rights to the medical information kept by Sunrise Behavioral Health and Support
Services, These rights are:
· Right to request restriction: You may request limitations from disclosure on your protected health information we may
disclose, but Sunrise Behavioral Health and Support Services is not required to agree to your request. If we agree, we
will comply with your request unless the information needed to provide you with emergency treatment.
· Right to confidential communications: You may request communications in a certain way or at a certain location.
· Right to inspect and copy: You have the right to inspect and copy your mental health information regarding decisions
about your health care. This does NOT include the right to inspect and copy psychotherapy notes. Sunrise Behavioral
Health and Support Services may charge a fee for copying, mailing and supplies. Under limited circumstances your
request may be denied. In the event that Sunrise Behavioral Health and Support Services denies your request to inspect
and copy, you may request that another behavioral health professional chosen by Sunrise Behavioral Health and Support
Services review the denial. The results of the review will be honored by Sunrise Behavioral Health and Support Services
· Right to request clarification of the record: If you believe that the information we have about you is incorrect or
incomplete you may ask to add clarifying information. You may request a form to make corrections or additions. Sunrise
Behavioral Health and Support Services is not required to accept the information that you provide on the correction/
· Right of accounting of disclosures: You may request a list of the disclosures of you behavioral health information that
have been made to persons or entities other than for treatment, payment, or health care operations in the last 6 years.
· Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you
have been provided with an electronic copy.
A patient also has the right to file a complaint if the patient believes that their medical information was violated.
U You will not be retaliated against or penalized for making a complaint. A patient also has a right to file a
complaint regarding privacy of their medical information with the Secretary of Health and Human Services toll
free at 1-877-696-6775.
Please contact your Behavior Analyst or Sunrise Behavioral Health and Support Services if you have a complaint,
any questions about this notice, you wish to request restrictions on uses and disclosure for health care
PATIENT SIGNATURE __________________________________________________ DATE _________________
PARENT SIGNATURE IF PATIENT IS UNDER 18 ____________________________________________________
Sunrise Behavioral Health and Support Services NOTICE OF PRIVACY PRACTICES