Benteh Wellness Center (BWC)

Intake Packet Fillable (no NPIF)

We look forward to working with you. Please take a few minutes to read the following information and sign and date where necessary indicating you understand and agree with the terms. If you have any questions or need assistance, please call our office at 907-671-6871 or email BWCReferrals@kniktribe.org

Other Documents Needed:

Forms can be submitted via this online form or emailed to BWCReferrals@kniktribe.org or returned to our office.

PARTICIPANT INFORMATION

Benteh Wellness Center

Informed Consent to Treat

This document contains summary information about the Health Insurance Portability and Accountability Act (HIPAA) and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices and explain HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information.

Therapy Services

• Therapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings such as sadness, anger, guilt, and helplessness. Therapy often requires discussing unpleasant aspects of your life. Therapy has also been shown to have benefits for people who actively participate.

• Your first few sessions will consist of a discussion between you and the provider to evaluate your needs and discuss diagnoses. After evaluation, we will discuss what our work may include and create an initial treatment plan. We will need ongoing feedback from you for your needs to establish the most successful treatment plan.

• Most sessions are scheduled for 50 minutes, usually weekly. Sessions are sometimes scheduled more or less frequently based on your needs.

• Repeated cancellations or no-show appointments may indicate that this isn’t the right time for services. Three missed appointments without participant contact may result in program discharge.

• If you do not notice improvement from therapy within a couple of months, please talk to your provider right away.

• Any questions you may have regarding any procedures can be addressed as they arise.

Telehealth Services

Telehealth services may be used when mental health providers cannot be physically present with you or your child during evaluations and therapy services.

• HIPAA compliant video platforms are used to communicate between you and your provider. The video communication software includes measures to safeguard data and protect against corruption.

• Privacy for you or your child at home should be considered so that all feel comfortable that the participant can continue to share what they need to with their provider.

• There are risks with the transmission of personal health information over technology that include but are not limited to: breaches of confidentiality (digitally or by being overheard), theft of personal information, and disruption of services due to technical difficulties.

• No recording of the session occurs or is stored without prior notice and signed participant consent.

Psychiatric Evaluation and Medication Management

• Psychiatric evaluation and medication management are performed by a psychiatrist or an ANP.

BWC does not currently offer this level of care.

Availability

• Providers are not available 24 hours a day. BWC’s standard office hours are Monday through Friday, 8am-5pm. If you cannot reach our staff and feel you or your child are in crisis, you may call your family physician, the Crisis Line at 1-907-376-2411, the Alaska Careline at 1-877-266-4357 or go to the emergency department at the nearest hospital.

Professional Records

• The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. If you provide our office with an appropriate written request, you are legally entitled to receive a copy of the records. Records may also be available on your patient portal.

Privacy of Minor Participants

• HIPAA states that minors have a right to privacy even though a parent can legally attain their records. Natural parents who have not had their parental rights terminated are able, by law, to access the child’s medical records unless it can be proven that this would not be in the child’s best interest. Our office asks parents and legal guardians to respect their child’s privacy and not access their treatment records.

• If your child is a danger to his or herself or others, your provider will discuss this with you immediately.

Confidentiality

The law protects the communication between participants and provider, and our office can only release information about our work with others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. We may disclose confidential information in the following circumstances:

1. Information shared in individual sessions or circumstances by a minor participant will be shared with the parents if the therapist finds it to be beneficial to the therapeutic process. High- risk behaviors may or may not be reported to parents – sexual activity and drug use disclosures are protected at a more stringent standard as stated in Alaska statutes.

2. We may occasionally find it helpful to consult with other mental health professionals about a case. We regularly staff participants in supervision. During a consultation, we make every effort to avoid revealing the identity of the participant. The other professionals are also legally bound to keep the information confidential. If you do not object, your provider may not always tell you about these consultations unless it is important to your work together. Your provider will note all consultations in your clinical record.

3. Disclosures required by health insurers in order to receive payment will be required. Depending on your insurance provider this may include a clinical diagnosis, treatment plan, and other relevant information in order to extend benefits. Though all insurance companies claim to keep information about you confidential, it will become part of their files and your provider has no control over what they do with it once it is in their hands.

4. There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, your provider will make every effort to discuss it with you before taking any action and your provider will try to limit any disclosure to what is necessary. When reporting child abuse, it may be deemed that it is not in the child’s best interest to discuss the situation with you.

5. The law requires the reporting of child physical and sexual abuse, both past, unreported events as well as current. This would include domestic violence witnessed by children, in addition to substance use that impacts parenting and child neglect.

6. An attorney may subpoena your provider’s records to court. It is office policy to protect participant confidentiality to the best of our ability. Alternatives, such as treatment summaries, will be discussed should this arise. If ordered by the court, however, your provider is obligated to disclose any information requested.

7. If your provider believes that a participant is threatening serious bodily harm to self or another, we are required to take protective actions, which may include notifying the potential victim, and/or notifying the police. In the case of suicidal preoccupation or intent, hospitalization for the participant or contact with family members or others who can help provide protection may be sought.

8. If a government agency is requesting the information for health oversight activities, your provider is required to provide it for them.

9. If a participant files a complaint or lawsuit against our office or your provider, we may disclose relevant information regarding that participant in order to defend ourselves.

Participant Rights & Responsibilities

Participant Rights – Treatment

1. You and your family have the right to be informed of these rights in a language and method you understand.

2. You have the right to designate a surrogate decision maker if you become incapable of understanding a proposed treatment/procedure or are unable to communicate your wishes.

3. You have the right to ask about the educational and professional background of providers as well as licensing information.

4. You have the right to reasonable access to care which respects your dignity, values and beliefs regardless of your race, religion, gender, sexual orientation, ethnicity, age or disability.

   You have the right to receive information about your treatment, alternative treatments and to seek a second opinion. Like other medical treatments, behavioral health treatment has benefits and risks and there are no guarantees with respect to outcome.

Participant Rights - Confidentiality

1. Once you sign an official release of information form and this information is released to another agency, we can no longer guarantee the confidentiality of this information.

2. Providers may be required to disclose information without your authorization to protect your safety or the safety of others including:

   
   

   • If you are in clear danger of hurting or killing yourself or are unable to care for yourself.

   • If you are in clear danger of hurting or killing someone else or have clearly threatened to hurt someone else.

   • If you tell a provider about neglect or abuse of a child, an elder or an individual who is unable to care for him/herself.

   • If a child is witnessing domestic violence within the home.

   • When records are subpoenaed or ordered to be released by a court of law.

   • For purposes of program accreditation, certification or state agency reviews and audits.

Participant Responsibilities

1. You have the responsibility to provide information about your present concern, past illnesses and medication to your provider. Parents/Guardians are responsible for providing the provider with timely and accurate updates and concerns for minor children.

2. You have the responsibility to ask questions about anything you do not understand during your assessment or treatment.

3. You have the responsibility to actively participate in treatment including keeping scheduled appointments.

4. You have the responsibility to follow the recommended treatment plan after adequate instructions have been provided. If you disagree with the recommended treatment plan, it is your responsibility to discuss these areas of disagreement with your provider.

5. You have the responsibility to accept the consequences of not following the recommended treatment plan.

6. You are responsible for seeking emergent mental health care when indicated. You may call your family physician, the Crisis Line at 1-907-376-2411, the Alaska Careline at 1-877-266-4357 or go to the emergency department at the nearest hospital.

7. You have the responsibility to fulfill financial obligations, if applicable.

Resolution of Concerns

• Participants and their families are encouraged to express any concerns or problems encountered during their course of treatment in a timely manner. Communication of concerns and problems are viewed as an opportunity to improve your treatment and services.

• Report concerns directly to your provider. If you think doing so is inappropriate, concerns can also be reported to a BWC manager.

• You may also report concerns to the BWC Compliance Department at 1-907-671-7390.

• Anyone, including visitors or employees, who believes possible participant discrimination or abuse has occurred, should immediately contact any BWC staff member.

• If you have serious concerns or complaints about a behavioral health practitioner, you can also contact the Division of Occupational Licensing, 3601 C Street, Suite #722, Anchorage, Alaska 99503-5986. Telephone number: (907) 269-8160.

Informed Consent to Treat

By signing this document, it indicates that you have read the information in this consent to treat and agree to abide by its terms during our professional relationship.

Benteh Wellness Center

Notice of Privacy Practice

This notice applies to services that are provided by Knik Tribal Council and the related records. For services provided at the Benteh Wellness Center (BWC), BWC respects your privacy and understands that your personal health information is a private and sensitive matter. We make a record of the care and services you receive at BWC that is called protected health information (PHI). This information is needed to give you quality health care and comply with the law. For example, this information includes your symptoms, test results, diagnosis, treatment, health information from other health care providers, and billing and payment information related to those services. We will not disclose your information to others unless you authorize us to do so, or unless the law authorizes or requires us to do so.

This privacy notice will tell you about:

1. The way that we may use and disclose health information about you.

2. Your privacy rights.

3. Special rules for patients of BWC’s alcohol and drug prevention and treatment programs; and

4. BWC’s responsibilities in using and disclosing your health information.

HOW BWC MAY USE & DISCLOSE YOUR HEALTH INFORMATION:

The following is an explanation and example of some of the ways your health information may be used and disclosed:

Treatment: We may use your protected health information for treatment purposes. Information obtained by our health care staff will be recorded in your health record and used to help decide appropriate care. We may also provide information to others providing your care. For example, medication information could be shared with nurses, pharmacists, or other providers to avoid treatment that might cause a negative reaction.

Payment: We may use your protected health information for payment purposes. “Payment” includes the activities of BWC to obtain payment or be reimbursed for the services we provide to you. For example, insurance companies may need information about services you received at an BWC program to authorize payment. In addition, if someone else is responsible for your health care costs, we may disclose information to that person when we seek payment.

Health Care Operations: We may use your protected health information for health care operations. “Health care operations” are certain administrative, financial, legal, and quality improvement activities

necessary to run BWC programs and make sure all customer-owners receive quality care. For example, we may use health information about you to evaluate the performance of our staff, or to evaluate services provided at BWC.

Electronic Health Information Systems: We utilize electronic health information systems, including an integrated multi-facility electronic health information system with a patient service communications network that permits providers involved in your care at other tribal health care facilities, and the Indian Health Service, to access health information accumulated about you at our facilities. Once information is entered into many of these systems, it can be amended, but it cannot be removed. Once a user is authorized to have access to your information contained in some of these systems, the user will continue to have such access until determined otherwise. We may make your protected health information available electronically through an electronic health information exchange to other health care providers and health plans that request your information for their treatment and payment purposes. Participation in an electronic health information exchange also lets us see their information about you for our treatment and payment and healthcare operation purposes. You are permitted to request and review documentation regarding who has accessed your information through the electronic health information exchange. Your provider will have information on how to make this request, or you may find the information on our website once we begin participating in the exchange.

Appointment Reminders: We may use and disclose health care information to contact you as a reminder that you have an appointment for treatment or health care at BWC. You may be contacted by staff to remind you that you have an appointment. We may use and disclose health care information during the reminder call, but the information disclosed will be kept to what is necessary to remind you of the appointment.

Interpreters: To provide you proper care and services, we may use the services of an interpreter. This may require the use or disclosures of your personal health information to the interpreter.

Other Treatments and/or Health Products: We may use and disclose health care information to tell you about or recommend possible treatment options or alternatives that may be of interest to you, or about health-related products or services that may be of interest to you.

Research: Under certain circumstances, we may use and disclose health care information about you for research purposes, but only if the research has been reviewed and approved by an Institutional Review Board (IRB). BWC may also share information with researchers preparing to conduct a research project. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at BWC. In some cases, your health information might be used or disclosed for research without your consent. For example, a researcher might review your health record to determine if we have enough patients to conduct a diabetes research study; or to include your information in a research database. In these cases, the IRB makes sure that using your information without your consent is justified and that steps are taken to limit the use of your information. In all other cases, we must obtain your authorization to use or disclose your information for a research project. We may also share or disclose your information for research purposes with researchers at other institutions.

Funeral Directors/Coroners/State Medical Examiner: We will disclose health care information about you to funeral directors, coroners, and the state medical examiner, consistent with applicable law to allow them to carry out their duties.

Public Health Risks: We may disclose health care information about you for public health activities that can include the following:

• Prevention or control of disease, injury, or disability.• Reports of births and deaths.

• Reports of abuse or neglect of children, elders, and dependent adults.

• Reports of reactions or problems with medications or health products.

• Notifying people of product recalls related to their health care.

• Notifying a person that they may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

• Notifying a government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Laws: We will disclose health care information when required by state law and/or when you have made a workers’ compensation claim that provides benefits for work-related injuries or illness.

Correctional Institutions: If you are in jail or prison, we may disclose health care information to the Department of Corrections for your health and the health and safety of others.

Law Enforcement: We may disclose health care information about you when legally required such as when we receive a subpoena, court order or other legal process, or when you are the victim of a crime.

Tissue Donation, Organ Procurement and Transplant: We may disclose health care information to organizations that handle organ procurement or tissue transplantation or to an organ donation bank, to help with organ or tissue donation and transplant if you or your family members agree.

Health and Safety Oversight: We will disclose health care information to a health oversight agency when required by law. These oversight activities include audits, investigations, and medical licensure.

Disaster Relief Purposes: We may disclose health care information to disaster relief agencies to assist in notification of your condition to family or others.

Military and Veterans: If you are a member of the armed forces, BWC may release health care information about you as required by military command authorities.

Court Orders, Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health care information about you in response to a court or administrative order in accordance with applicable law. We may also disclose health care information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

National Security and Intelligence Activities: We may release health care information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Business Associate Agreements: We may use your health care information and disclose it to individuals and organizations that assist BWC with treatment, health care operations or payment purposes or with

complying with legal obligations. For example, BWC may disclose information to consultants or attorneys who assist us in our business activities. These business associates must agree to protect the confidentiality of the protected health information.

Other Uses and Disclosures: We may also use and disclose your information to enhance health care services, to protect patient safety, to safeguard public health, to ensure that our facilities and practitioners comply with government and accreditation standards and when otherwise allowed by law.

For example:

• We may use certain information about the care you received at BWC to fundraise for the benefit of BWC. If we engage in fundraising, you have the right to opt out of receiving such communications.

• We provide information regarding FDA regulated drugs and devices to the U.S. Food and Drug Administration.

• We provide government oversight agencies with data for health oversight activities such as auditing or licensure.

• We provide notices to appropriate individuals when we believe it necessary to avoid a serious threat to health or safety or to prevent serious harm to an individual; and

• We disclose information when otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining our compliance with our obligations to protect the privacy of your health information.

Notification of Family and Others: Unless you object, we may release health information about you to a friend or family member who is involved in your health care while you are receiving services. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a residential BWC facility. If you would like to restrict the information provided to family or friends, please contact the appropriate number at the end of this notice.

If you want a family member or friend to be able to access information about you or assist in arranging your health care, such as scheduling or checking on appointment times, please make sure that an authorization is on file for that person to access your records. This will be required for individuals to assist you in this manner.

Uses and Disclosures That Require Your Authorization: Other than the uses and disclosures described above, information will be used or disclosed only as allowed or required by law, or with your written

authorization. Uses and disclosures such as the release of psychotherapy notes, uses for marketing and the sale of protected health information require your prior written authorization. If you provide us with written authorization, you have the right to revoke that authorization at any time unless the disclosure is required by law or in circumstances where we have otherwise relied on the authorization or the law prohibits revocation.

SPECIAL RULES FOR ALCOHOL AND DRUG PREVENTION AND TREATMENT RECORDS

If you receive alcohol and/or drug prevention and treatment services, your medical records that identify you as receiving those services are protected not only by HIPAA, but also by the 42 CFR Part 2 confidentiality law. This law provides additional safeguards to protect the privacy of these records.

BWC must obtain your written consent before disclosing information identifying you as a patient of an alcohol or substance abuse treatment program, including before releasing information for payment purposes. BWC may condition treatment on receiving your consent for payment purposes. Federal law does, however, permit BWC to release records identifying you as a patient of an alcohol and/or drug prevention or treatment program in certain circumstances without your written authorization. These are disclosures:

• Pursuant to an agreement with a qualified service organization or business associate.

• For research, audit, or evaluation purposes:

• To report a crime against BWC personnel or on BWC property.

• To medical personnel in a medical emergency.

• To report suspected child abuse or neglect to appropriate authorities; and

• Pursuant to a court order.

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BWC, for example, may disclose your records identifying you as a patient receiving alcohol and/or drug prevention or treatment services without your consent if a judge issues a Court Order that requires BWC to provide the records for a court hearing or active lawsuit. To the extent anything in this Notice conflicts with the protections described in this special section regarding substance abuse treatment, the portion of the Notice providing you with greater protection will apply.

YOUR INDIVIDUAL RIGHTS REGARDING YOUR HEALTH INFORMATION

You have specific individual rights as to the uses and disclosures of your protected health information. The health and billing records we make, and store belong to BWC. The protected health information in it, however, generally belongs to you. You have the following rights:

• Questions - You have the right to ask questions about any information contained in this notice.

• Notice - You have the right to receive a copy of this Notice of Privacy Practices.

• Right to Request Restricted Use – You have the right to ask BWC to limit certain uses and disclosures. If you want to limit use and disclosure, you must give us a written request. We are not required to grant the request except under special circumstances, such as a restriction on information provided to an insurer for services paid for out-of-pocket. If we grant your request, we will comply with it unless the information is needed to provide emergency services

• Right to Confidential Communications - You may request that your health information be given or sent to you by another means or at another location. These requests must be made in writing and we have a form available for this type of request. BWC will accommodate reasonable requests.

• Right to Request an Inspection and Receive Copy– You may request to see and get a copy of your health record. If your health record is in electronic format, you may request that your copy also be in electronic format and BWC will comply if the requested electronic format is reasonably available.

• Right to Request an Amendment to Your Record - You have the right to give us a written request to change your health information. We may accept your request and if we do, we will add an amendment to your record. If we deny your request, you may write a statement of disagreement that will be stored in your health record. Please note that we may add our own statement disagreeing with your proposed changes. All statements regarding changes in your health record would be included with any release of your records.

• Revoke or Cancel Prior Authorizations - If you provided us authorization to use or disclose your health information, you may revoke your authorization in writing at any time. Once you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written permission. However, we are unable to take back any disclosures we have already made with your permission, and if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.

• Right to Know About Disclosures - You have the right to request a copy of the list of certain disclosures made of your health information outside of treatment, payment, and operations. This list will not include disclosures to third party payers. You may request an accounting at any time. BWC is only required by law to provide one accounting without charge during any 12-month period. We will notify you of the cost involved if you request this information more than once in a 12-month period. In some cases, we may be delayed in providing you a list of certain disclosures if required by law to not disclose. The list of disclosures will go back prior to the date requested for a period of six years for paper records and for electronic health records to six years prior or the date the electronic health record came into existence, whichever is later.

WHO WILL FOLLOW THIS NOTICE

• Any individuals authorized by BWC to enter information into your health record.

• All BWC departments and programs.

• Any member of a volunteer group we allow to help you while you are receiving services at BWC; and

• All individuals who are considered members of BWC’s workforce.

BWC’s RESPONSIBILITIES

We are required by law to:

• Keep your protected health information private.

• Provide notice of our legal duties and privacy practices with respect to protected health information.

• Notify affected individuals following a breach of unsecured protected health information.

• Give you this Notice of Privacy Practices; and

• Follow the terms of the Notice of Privacy Practices currently in effect.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling or visiting any of our BWC programs and asking for it or by visiting our website

www.kniktribe.org.

TO ASK FOR HELP, EXPRESS A CONCERN OR COMPLAINT

If you have questions, want more information, or want to report a problem about the handling of your health information, you may contact:

• Benteh Wellness Compliance Department: 907-671-6863

If you believe your privacy rights were violated, you may file a written complaint to:

• Compliance Officer c/o Benteh Wellness Center 2521 E. Mountain Village Drive, Ste B PMB 797, Wasilla, AK 99654 or to:

• Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue. S.W. Room 509F, HHH Building, Washington, D.C. 20201

  
  

  There will be no retaliation for filing a complaint.

  
  

NOTICE OF PRIVACY PRACTICES Acknowledgement

Effective Date April 14, 2003

Benteh Wellness Center (BWC) Notice of Privacy Practices provides information about how BWC may use and disclose protected health information about you. You have the right to review the notice before signing this acknowledgement. As stated in the notice, the terms of the notice may change. If the notice is changed, you may obtain a revised copy by contacting the Compliance Department or asking any BWC clinical desk staff.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction except in special circumstances, but if we do, we are bound by our agreement.

You have the right to request a list of certain disclosures we have made of your protected health information.

By signing this form, you acknowledge receipt of BWC’s Notice of Privacy Practices.