We are required by laws including HIPPA and 42 CFR Part 2 to maintain the privacy of and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with us by contacting us directly by the phone number listed on this website. 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.

Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional or Treatment Center.


Purpose: The purpose of this policy is to ensure records are protected in accordance with Federal and State requirement.

Policy: It is the policy of First Step Recovery Center to ensure that all records are kept in a protected private manner for a period of time consistent with state, federal, and corporate requirements and to meet the needs of the client and First Step Recovery Center.

Procedure: First Step Recovery Center will retain and preserve client records and information to meet legal requirements and minimize the risk of litigation losses. Records will be retained in the most secure manner possible through KIPU a privacy-protected Electronic Medical Record. First Step Recovery Center client records are the physical property of First Step Recovery Center. However, the client is the owner of the information contained in the record and therefore has the right to authorize the release of information or to refuse such release except as outlined in this policy. It is First Step Recovery Center’s duty and responsibility to protect and preserve the information contained in the records. All client information is considered confidential. Release of information from First Step Recovery Center is carried out in accordance with all applicable State and Federal regulations, accrediting and regulatory agency requirements and the rules outlined in this policy. First Step Recovery Center shall retain client records, in original form stored on the private and protected EMR, for a period of 7 years after the most recent care.


Who May Consent to Release Information: Federal confidentiality regulations prohibit the disclosure of records regarding alcohol or drug abuse treatment to anyone (with a few exceptions) concerning or identifying a client, former client or deceased client unless the client or legal representative has consented in writing. Even the fact that the client is being or has been treated may not be disclosed without valid consent. In general, the following persons may consent for the release of confidential information:

· A competent adult client

· Client’s legally responsible person (i.e., parent/appointed guardian, power of attorney, executor/administrator of estate). In this case, obtain and retain copies of legal documents showing guardianship or representative status in the medical record.

Release of Information without Client Authorization: Authorization by the client for release of information is not required in the following circumstances:

· Organized company committees entrusted with the review of the quality of care provided by First Step Recovery Center and their designees.

· Survey activities by accrediting and licensing agencies

· Reporting of child abuse, elder abuse or communicable disease as required under State statutes

· Research where the name of the client or any other client identifying information (such as social security number) is not revealed and the research has been approved by the Leadership/Quality Council/Ethics Committee

· A medical emergency arises in which a life-threatening situation exists and consent is unobtainable from the client or legal representative

o In this case, record the following information in the medical record:

o The date the information was released and method (i.e. phone, fax etc.)

o What information was released

o The person or facility to whom the information was given

o The nature of the life-threatening situation and the reason the consent could not be obtained

o The name of the person releasing the information

· Duty to Warn

· Receipt of a valid court order from a local (same state) court. If the court order is in relation to an alcohol/substance abuse client, it must also meet the requirements of federal law.

Client Request to Review Record: A request by a client to view or obtain a copy of the client’s record should be referred to his/her primary therapist and/or healthcare provider due to the sensitive nature of the information in the record. The client should first be encouraged to set up an appointment with his/her primary therapist and/or healthcare provider to review, or have the information sent to another mental health or medical professional to review for and/or with the client.

In accordance with applicable State law, if neither of these options satisfies the client, and it is the healthcare provider’s opinion that it would be detrimental to the client’s mental stability to read his/her own record, the healthcare provider may disapprove/deny the request for the client to have access to his/her record. This refusal and the justification for the refusal should be documented in the client’s record.

Consent for Release of Information: Except as provided by law, the prior written consent of the client, or his/her legal guardian, is required for release of medical, mental health, and substance abuse treatment information.

A properly completed authorization to release client information should include at least the following information:

· Name of individual/facility that is to release the information

· Name and address of individual/facility that is to receive the information

· Client’s full name and date of birth and/or social security number (completed in full for identification purposes)

· Purpose or need for information

· Extent or nature of information to be released (discharge summary, psychological evaluation, etc.)

· Dates of service covered by the authorization

· Signature of client or legal representative and date the authorization is signed

· Signature of witness and date signed

· A statement that the consent is valid for only a specified period of time

· A statement of revocation such as “I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on this authorization.”

· A statement of acknowledgment that psychiatric, substance abuse and HIV information may be contained in the records being released, for example, “I understand that information to be re- leased may include information regarding drug or alcohol abuse, psychological or psychiatric impairments, confidential communications, HIV and/or AIDS, physical conditions or other in- formation which may be privileged or confidential under State and/or Federal law.”

Clients/legal representatives are not to sign blank release forms. The forms should be filled out in their entirety prior to obtaining consent signatures.

Anytime the signature of the client is questionable, the client should be notified and the legitimacy of the client’s signature on the release should be determined. If the prior release is illegible or has expired, obtain another release signed by the client before release of any information or records.

If an adult client is mentally incapacitated to sign legal documents for him-/her-self, a legal representative, or Durable Power of Attorney for Healthcare, may sign for the client. A copy of the Durable Power of Attorney for Healthcare should be obtained and included in the medical record.

A Financial Power of Attorney (i.e., regarding the client’s bank account) or being designated as the as- signee of benefit checks does not necessarily entitle that person to provide consent for the release of the client’s records. In all cases (Durable Power of Attorney for Healthcare), the legal document should be reviewed to determine the extent of representation.

For deceased client, the authorization must be signed by the legal executor or administrator of the estate. A copy of the court document that designates the administrator/executor of the estate must be provided for the record as well as the death certificate.

Illiterate clients should have the consent read to them in terms they understand. The signature can be indicated by an “X” and two signatures must attest to witnessing this. Note on the release that the con- sent was read to the client and that the client is illiterate.

If written consent cannot be obtained, verbal authorization is acceptable when it is witnessed by two parties. The circumstances of the verbal consent should be documented on the release form and both parties should sign as witnesses.

The client will initial and date the release form in the designated section if he/she understands and agrees to the consent.

The client will have the opportunity to rescind the consents and authorizations, except to the extent that action was taken in reliance thereon.

If the client wishes to revise the consent and authorization, the original will be rescinded and a new consent and authorization will be a completed.

The consents and authorizations to release information are obtained for admission and apply to that admission. If a client agrees to the release of medical records for “all dates of treatment” client information may be released for the current admission and all prior admissions.

Written consents must be dated within one (1) year for the treatment program, and five (5) years for continuing care for the consent to be considered valid.

An authorization should not be honored if:

· The client has rescinded the authorization.

· There is doubt that the person requesting the information is the person named in the authorization.

· There is question as to the legal guardian who has signed the authorization for a minor, incompetent client or deceased client.

· There is question as to the authenticity of the client’s signature.

· The client consented to release of information for future episodes of care. Authorization for in- formation forms should not be honored if they are signed and dated prior to the treatment episode for the information requested.

· The authorization has expired.

Release of Records: Information released to authorized individuals/facilities should be restricted to that information expressly covered by the authorization.

All information released by First Step Recovery Center should be accompanied by the Federal re-disclosure statement: “This information has been disclosed to you from records whose confidentiality is protected by Federal law. Federal regulations (42 CFR, Part 2) prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization

for the release of medical or other information is not sufficient for this purpose. The Federal Rules re- strict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.”

Each page of released information shall have a confidentiality statement warning against re-release of the information.

Copies of information received from other facilities are not to be recopied and released to any other facility. The requesting facility should request and receive copies of records they need from the originating facility.

Original medical records should not be taken outside First Step Recovery Center except in response to a valid court order specifically ordering the original records or for secure off-site storage.

When information, written or verbal, is released to an agency or an individual, a notation should be made in the client disclosure database regarding:

· What information was released and method of release. (i.e. fax, phone, written, etc.)

· The dates of service covered in the information

· The date the information was released

· To whom the information was released

· For what reason

· A notation should be made on the release of information form

When written information is to be released to a licensing board, impaired professionals’ organization or for other highly sensitive releases of information, the information to be released will be reviewed and approved by the Executive Vice President prior to release.

Faxing should be done only in extremely rare circumstances (i.e. in a medical emergency and where dis- closure of needed information is not feasible over the telephone, mail or overnight delivery). Use the same guidelines as noted previously to determine whether release of the information has been authorized in writing. If relying on facsimile signature to permit the release of records, carefully compare prior signatures of the same person to ensure accuracy.

Contact Information

First Step Recovery Center welcomes your questions or comments regarding this Statement of Privacy by calling us at 760-780-1237 during normal business hours. If you believe that we have not adhered to this Privacy Statement, please contact First Step Recovery Center in writing by certified mail at 12402 Industrial Blvd. Suite B-6, Victorville, CA 92395