235 South Eisenhower Ave.
Mason City, Iowa 50401-1562
Telephone (641)424-2075
Toll Free (800) 700-IOWA
Fax(641)424-9555
www.mhconi.org

Consumer Fee Information

Privacy Notice

Mental Health Center of North Iowa

235 South Eisenhower Avenue

Mason City , Iowa 50401-1562

Phone (641)  424-2075     Fax (641) 424- 9555

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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Effective Date:  April 14, 2003

Purpose of this Privacy Notice

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treat­ment, initiate payment, conduct health care operations and for other purposes permitted or required by law.  The Mental Health Center of North Iowa does reserve the right to make changes in this Notice of Privacy Practices.  The Notice describes your rights to access and control your protected health information.  “Protected health information” is information about you, including demographic information that may identify you and that relates to your past, present or future physical health, mental health, mental health condition and related health services.

Who will Follow this Notice

This notice describes the privacy policies of the Mental Health Center of North Iowa as they apply to all employees, con­sultants and associates of the Mental Health Center of North Iowa.  The Mental Health Center of North Iowa maintains further policies, procedures and practices to ensure effective implementation of the privacy practices.  We want to ensure that you  have a copy of this privacy notice and to have your written acknowledgement of your receipt of  this notice.

Our Pledge Regarding Health Information

The Mental Health Center of North Iowa considers the personal information you share with us as confi­dential and to be pro­tected.  We take a number of steps to protect, and safeguard this privacy in how we record, file, store and when we release information.  A record of care and services you receive through us is created and maintained by us.  This notice applies to all those records of your care.  We are required by law to:

• Make sure that health information that identifies you is kept private.
• Provide you this notice of our legal duties and privacy practices regarding your health information. 
• Follow the terms of the notice that is currently in effect.  We may change the terms of our notice at any time.  Any new or changed notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  You may obtain a copy by contacting our main office or ask for one at the time of your appointment with us.

This Notice of Privacy Practices further explains our policies and the exceptions that by law we will observe in the disclosure of personal health information.

I.  How we may use and disclose protected health information

The Mental Health Center of North Iowa uses and discloses health information in each category listed below which we give examples of in order to explain what we mean.  The examples are not intended to describe all the specific uses or disclosures of health information.

1. Use and disclosure for Treatment:  We will use and disclose your health information with your consent which you give us in writing at time of intake. With your further written authorization, we may also use and disclose your health information to coordinate and manage your health care and related services.  For example, with your autho­rization, we may disclose information to a case manager, or another service provider you are working with.  Staff may discuss your care in an internal case conference.  We do make the exception that, unless you object, you give us consent and we will not seek further authorization from you to release the minimum necessary information to those you involve in helping to arrange appointments and travel, labs and pharmacies. Unless further exceptions are noted by law and are noted in the Privacy Notice, the Center will release information for treatment only on the basis of your authorization.  In emergency conditions, we may accept your verbal authorization only until you can provide this authorization to us in writing.  An authorization is a written document that explains in detail the communication you are authorizing, which you sign  and which a copy will be made available to you.

2. Use and disclosure for Payment:  We will secure your written consent to release information for payment of ser­vices as part of the consent to participate in treatment.  Based on your consent, we may use or disclose your health information without your further authorization so that services you receive are billed to, and payment is collected from, your health plan or third party payer or to the County Central Point of Coordina­tion.  By way of example, we may disclose your health information to help deter­mine eligibility, to determine if services are necessary or are appropriate, to justify charges, or as part of your health plan’s review of utilization of services, or to justify continued services.  Our staff will review each request.  If the request goes beyond what we consider to be the minimum necessary information to address the question, we may ask for your further involvement and authorization.

3. Use and disclosure for Health Care Operations:  Your consent to treatment proved that we may use and disclose health information about you without your further authorization for our own internal health care operations.  These uses are necessary to run our organiza­tion and ensure quality care.  These actions may include, by way of example, quality improvement, reviewing per­formance of clinicians, training in clinical functions, licensing, accreditation.  We may use health care information by de-identifying it so data can be used for planning and service delivery with­out its personal identification.  We may provide your health information to your health plan to assist them in performing their own health care operations.  We may also use and disclose your health information to contact you to remind you of your appoint­ment or changes to appointments.  Unless you have requested a restriction that has been accepted by the Center, We may do so by way of phone contacts to numbers you designate including leaving of telephonic messages and by mail.

II.  Uses and disclosures that may be made without your further authorization but which you have the right to object

The Mental Health Center of North Iowa will secure your consent to treatment at the time of intake that provides for our being able to convey limited information to parties you involve in your services for appointments, travel, labs, and pharm­acies which you have the right to object. The Center will release the minimum necessary information to those you involve in helping to arrange services which includes travel and appointments, laboratory and pharmacy assistance.  Examples include a spouse who you have asked to call to arrange for an appointment, a family member who calls to help arrange transportation, or a family member who is assisting you with a medication refill at a pharmacy.  Only that information needed to address the specific service coordination request will be given under such circumstances.  Situations that require more information or which are on-going in nature will be situations where we will seek your further authorization.  The Center may also contact you in scheduling of appointments or for appointment reminders and may transmit disclosures by fax transmissions.

III.  Uses and disclosures that may be made without your consent or authorization or opportunity to object

Federal and state law set the conditions under which the Mental Health Center of North Iowa may release your health informa­tion without either your consent or authorization and are listed below.  

• Reporting suspected child abuse or neglect
• Reporting suspected adult dependent abuse or neglect
• Responding to a court order
• Disclosures in legal proceedings
• Worker compensation
• Responding to dangerousness to self or others
• To correctional officers for the purpose of treatment or safety
• Compliance with laws related to workers compensation
• National security provisions
• Health oversight activities including accreditation, audits, investigations, and regulatory reviews
• Under limited circumstances, specific and limited information may provided by a mental health professional to parents, children, spouse or siblings of an adult with chronic mental illness
• To law enforcement when there has been a gun shot wound, where a crime has occurred against us, or to help in an emergency where there is dangerousness to self or others, or to assist in an location in an emergency
• To the Food and Drug Administration to  report such things as adverse effects of prescribed medications
• Inmates – if you are an inmate of a correctional facility
• Sale or Closure of Practice – in the event that the Mental Health Center of North Iowa is sold or acquired by another organization, your protected health information will be disclosed to that entity.
• We are required under law to inform you when such a disclosure is made unless there is thought to be harm and when required by to the Secretary of the Department of Health and Human Services to investigate or determine our compliance with requirements of HIPAA.
• You have the right to have an accounting of disclosures

IV.  Uses and disclosures of your health information with your permission

The Mental Health Center of North Iowa initiates and continues treatment based on your informed consent which you pro­vide in writing to us and which is further acknowledged in this Privacy Notice.  The Center treats the personal information you give to us as confidential.  Unless it meets a condition noted elsewhere in this Privacy Notice, the Center will require your permission and authorization to release and to exchange information, unless one of the exceptions under law applies. Those exceptions are noted in this Privacy Notice.  This means we will ask for your specific authorization to release informa­tion to a designated party, for a specific purpose, covering specified information and which is time or duration limited. You will be asked to sign this authorization after reviewing and agreeing to its contents. 

The Center maintains a release of information form for the express purpose of securing your authorization in writing.  The release is reciprocal allowing us to release and to exchange information with the party you designate unless you limit this release to a one way communication release which can be noted on our form.  The Center will release the minimum neces­sary information to address the release of information. You have the right to a copy of the authorization and to revoke the authorization at any time which will only affect any future communications.  The Center must receive the revocation in writing and it will only cover release of information from the date the revocation becomes effective.

V.  How we will communicate with you

Unless you provide us a reasonable alternative means of communication, the Center will communicate with you through the telephone numbers and mailing address you provide.  Alternative means must be given to the Center in writing and agreed to by us.  All reasonable requests will be accommodated. Unless you object and request restrictions, the Center will communicate with you by mail and telephone around such issues as appointments or returning of phone calls.  This includes the necessity of leaving a message at the numbers you have designated. Your authorizations in communication extend to oral, written and electronic transmission. When responding to requests for authorized information, we will receive and send information by fax transmissions when mail and phone contacts to the other party are not timely to address the information needs.

VI.  Your rights regarding your health information

The Mental Health Center of North Iowa recognizes that you have the following rights regarding your health information:

1. The right to request restrictions of your protected health information and on certain uses and disclosures of your health information.  This means you may make further restrictions on the use of protected health information in treatment, payment or health care operations.  We are not be obligated to agree to the restrictions if there is a good reason.  If we agree to the requested restriction, me may not use or disclose your protected information unless in an emergency.  You may request a restriction by contacting and discussing the issue with our Privacy Officer.
2. The right to receive confidential communication from us by alternative means or at an alternative location.  We will accommodate reasonable requests in contacting you.  We may also condition this accommodation by asking that you provide us with information as to how appointments may be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for your request.  You must make your request in writing to our Privacy Officer.
3. The right to inspect and copy protected health information unless it is considered to be of serious harm or is other­wise limited by law.  Under federal law, however, you may not inspect psychotherapy notes, information compiled in reasonable anticipation of, or for use in a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access.  Depending on the circumstances, a decision to deny access may be reviewed.  In some circumstances, you may have the right to have this decision reviewed.  Please contact our Privacy Officer if you have questions.
4. You may have the right to have us amend your protected health information.   This means you may request an amend­ment of protected health information about you in our designated record set as long as we maintain this infor­mation.  In certain cases we may deny your request.  If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal and provide you with a copy.  Please contact our Privacy Officer if you have questions about amending your health information
5. The right to receive an accounting of disclosures of your protected health information for purposes other than treatment, payment or health care operations.
6. The right to have a copy of this Privacy Notice.  You will receive a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.  You will find our Privacy Notice on the Center’s web site:

 www. mhconi.org

VII.  How to complain about our privacy practices

If you think the Mental Health Center of North Iowa may have violated your privacy rights, or you disagree with a decision we have made about access to your information, you may file a complaint with our Privacy Officer at 235 South Eisenhower Avenue , Mason City , Iowa 50401-1562 .  Our phone number is (641)424-2075.

You may also send a written complaint to the Secretary of the Department of Health and Human Services, 200 Independence Avenue SW , Washington DC 20201 . We would like to address any such concerns.  The Center will take no retaliatory action against you if you file a complaint about our privacy practices.

VIII.   Mental Health Center of North Iowa’s responsibilities under this Privacy Notice  

The Center agrees to abide by the terms of its Privacy Notice currently in effect.  This Privacy Notice was developed on January 28, 2003 and goes into effect on April 14, 2003 .  The Mental Health Center of North Iowa reserves the right to make changes retroactively to this Privacy Notice and will post any changes in advance of their effective date.  Changes made by the Mental Health Center of North Iowa will be reflected in a revised Privacy Notice that will be available to you.  

Consumer Acknowledgement

I acknowledge that I have received a copy of the Mental Health Center of North Iowa’s Privacy Notice and orientation packet or that a copy has been made available to me. 

_________________________________ ______________

Signature of Consumer                                       Date  

or legal representative  

Consumer’s name___________________________________

                                                  (Please Print)

Witness____________________________________________

Consumer Acknowledgement

Of

Notice of Privacy Practices

I acknowledge that I have received a copy of the Mental Health Center of North Iowa’s Privacy Notice or that a copy has been made available to me. 

_______________________________ __________________

Signature of Consumer                                          Date  

or legal representative  

Consumer’s name___________________________________

                                                  (Please Print)

Witness____________________________________________

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Orientation To Services

Mental Health Center of North Iowa

235 South Eisenhower Avenue

Mason City , Iowa 50401-1562

Phone (641)  424-2075     Fax (641) 424- 9555

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Orientation to Services

Mission

The Mental Health Center of North Iowa is a private not-for-profit organization that was formed in 1955 to improve the mental health of the citizenry of North Iowa through a variety of community based mental health services that offer a collaborative and partnering relationship with consumers.

The Mental Health Center Board and staff want your visits with us to be productive and your con­cerns to be effectively addressed.  Through a responsive therapeutic relationship with you, we aim to bring a greater sense of personal power and satisfaction to your life.

Understanding

We want to understand better the concerns, the events and the conditions that have occurred in your life that brought you to the Mental Health Center .  We, therefore, will be asking you to share personal information.  We will honor our responsibility to you by doing so in a professional way.  We need your assistance in being as involved as possible and providing us with complete and accurate information.

Responding

Together we will build a plan of action – one that is based on your needs and targeted to address your goals.  Such a plan will be developed in writing as part of your visits to the Center.  We will want to stay focused on your goals as we meet together and we will regularly review progress on achieving those goals.  It is our practice to work collaboratively with other service providers that you may be seeing as well as with family when that is appropriate.  Any such involvement, however, would come through your informed consent.

Rights and Responsibilities

We want you to know that as a consumer here at the Mental Health Center you have rights.  Those include:

Rights

1.      To be treated with respect and dignity,

2.      To receive care based on my own individual situation and needs,

3.      To receive services in the least restrictive setting fitting my needs,

4.      To actively participate in the choice regarding the development, implementation and evaluation of treatment,

5.      To make my own decision to accept or refuse treatment,

6.      To express opinions about the services of the Center,

7.      To be able to appeal decisions about Center services or the operations that affect me,

8.      To be informed of assessment findings and recommendations for treatment,

9.      To make my own choices regarding participation in any clinical research proposed,

10.  To be informed of my financial obligations for services provided,

11.  To confidentiality under Federal and State law,

12.  To have services take into account my cultural, language, hearing, visual, cognitive, or other special needs,

13.  The right to confidential communication and to do so through alternative means or methods of contact,

14.  The right to request restrictions on the use and disclosure of my health information,

15.  The right to view, copy and request amendments to my health information

Responsibilities

As a consumer of the Mental Health Center of North Iowa, you also have responsibilities that are critical to achieving the results you desire.  The work we do requires your active involvement and commitment in:

1.      Participating in the identification of my needs,

2.      Providing reliable and honest information,

3.      Participating in my own treatment,

4.      Participating in setting and directing my own goals for services,

5.      Identifying family, significant others, and providers to involve in your treatment and to define the conditions of their involvement,

6.      Keeping scheduled appointments,

7.      Keeping my account with the Center current and discussing problems if they should exist with my therapist and business office.

Communication

We will communicate with you about your services and appointments through mail and telephone.  We will do so respectfully and discretely.  However, we may leave you a message on your home answering machine if we cannot contact you directly.  If we do so, we will only leave the minimally necessary information.  For example, we may call to cancel an appointment or to rearrange an appointment time.  When using and disclosing information, we rely on oral, written and electronic means of communication.  This may include, for example, letters, telephone calls and fax transmissions to other providers.  You may object and you may request an alternative means of contact with us.  Your alternative, however, must be reasonable and one that we agree to.  You also may request restrictions on confidential communications which are subject to our agreement.  Unless you object, our policy will be to communicate minimally necessary information to those you involve with your services for scheduling of appointments, arranging of transportation, labs and pharmacies.  We will only release that information that is minimally necessary.  Your further authorization will be required if the communication requests extend beyond this level of disclosure.

Confidentiality

Information you share of a personal nature is confidential.    Information regarding care may be shared internally with other professional staff to ensure effective services but will not be released outside our agency without your consent. The Center takes a number of steps to protect and safeguard this privacy in how we record, file, store, and when we release information.  There are exceptions to this policy that, by law, we are required to observe:

1.      Child abuse/neglect,

2.      Adult dependent abuse/neglect,

3.      Imminent threat to self or another party,

4.      Court order, judicial and administrative proceedings,

5.      Site visitations by a regulatory body and other health oversight activities including accreditation and auditing as may be required by law,

6.      Administrative, diagnostic and minimally necessary service information as required by a third-party payor or the county’s Central Point of Coordination for payment,

7.      Under certain circumstances defined by law, disclosure of limited mental health information may be released to parents, children, spouse or siblings of an individual with a chronic mental illness, and

8.      To law enforcement when there has been a gun shot wound or when a crime has been committed against us or on our premises.

Emergencies

The Center has services that are responsive to your emergency needs.  During the day, the Center has a staff member available to return calls or respond to emergencies if your therapist is not available.  If you exper­i­ence an emergency after working hours or on the weekend, you can still contact us. A member of our clinical staff will be on call for emergencies.  The phone call is first received by an answering service who will take the message and page the staff member on call.  You can reach us by calling (641) 424-2075 or 1-800-700-IOWA.

When There is a Problem

We value your opinions and you have the right to express questions, concerns, complaints, or grievances regarding any aspect of our service.  Please direct your questions as directly as possible to the staff person with whom you are working.  You may also contact the Center’s director if your question or concern has not been adequately addressed.

The Center has an appeal process that you may use if you have a problem with a service, a procedure, or a policy.  The process follows the steps below.  Our appeal procedure is posted in the lobby and you may discuss it with our staff if you are uncertain as to how to proceed.

Step #1:  Take the problem up directly with the person with whom you have the problem,

Step #2:  Take the problem to the Center supervisor,

Step #3:  Reduce the issue to writing and send to the director,

Step #4:  Written issue submitted to the Board of Director’s Executive Committee.

Cancellation Policy

You are encouraged to be an active participant in scheduling of appointments.  We ask that you schedule appointments that work for you.  The Center understands that there are times you will need to cancel or reschedule an appointment.  Please let us know as early as possible if you need to reschedule.

We ask that you call 24 hours or more in advance or a charge may be incurred.

Failed Appointment Policy

The Center will ask that you discuss patterns of numerous failed appointments or a pattern where more than two are missed/canceled in a row.  The Center does reserve the right to limit service if we are unable to address the problem.

Insurance and Third-Party Coverage

Many insurance companies provide coverage for mental health services.  When third-party payors are involved:

·        The insurance company is billed the full cost of service,

·        Insurance forms and necessary information regarding the policy needs to be provided by the consumer,

·        Payment of the consumer fee (co-payment) is expected at the time of the visit.

Financial Accounts

As a private not-for-profit organization, it is necessary for the Center that accounts be kept current. We ask that you make payment at the time of each visit.  A past due account is one that is 30 days old. The Center reserves the right to limit further service when an account becomes substantially late--90 days or more.

Service Fees

The Center utilizes cost-finding procedures in determining all service rates.  You as the consumer will be responsible for the cost of the service provided.  You may be eligible for an adjusted fee based on a sliding scale.  If you have health insurance coverage, the Center requires that you allow us to file that insurance if you wish to access the sliding scale.  The Center will process insurance and/or other third-party payors to help defray the cost of your visits; however, insurance companies and other third-party payors are not eligible for the sliding scale. In some cases, insurance companies require that they be notified in advance in order to authorize payment for services. In those cases, it is your responsibility to be aware of your insurance benefits and to pre-certify services if necessary.  We will be available to assist you with this at your request.

We look forward to working with you collaboratively in addressing your identified concerns that bring us together.  You may want to retain this handout along with the Consent Form and Release of Information forms, and other information from us as reference information.  If you have any questions or concerns, please let us know.

Ken Zimmerman, LISW

Executive Director

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CONSUMER FEE INFORMATION

To help defray the expense of treatment, a fee is charged for services.  Each year a fee schedule is estab­lished by the Board of Directors based on a sliding fee scale taking into consideration each consumer’s income and family size.  The sliding scale is utilized only after all other forms of insurance are pursued.  The Mental Health Center has the ability to offer the sliding scale based on county financial support.  The fee is established at the time of the first visit when you are asked to bring your most recent Federal Tax Return.  Self-supporting students, those un-employed, and those on Social Security are charged an appropriate fee.

At the time your first appointment was made, you will have been asked to bring your Federal Income Tax Return with you in order to establish a fee.  If you have forgotten your Return, you should bring or mail in the form (it will be returned to you immediately) prior to making your second appointment.

Any consumer eligible for Title XIX, VA Insurance or other third-party payment should bring this informa­tion at the time of the first visit.

The fee schedule is reviewed annually and, if necessary, revisions are made.  The fees will then be adjusted effective July 1^st of each year.  Each consumer should bring in the Federal Tax Return annually to ensure that they receive fair and equitable fee determination.

In the event of any unusual circumstances or expenses which affect the consumer, please notify the office immediately for consideration of a fee adjustment.  If you are interested in a copy of your fee schedule, it is available upon request.

Payment for services is encouraged at the time of the visit or when the monthly statement is received.  Any account not paid after 30 days is considered past due.

Due to the demand for services and the nature of treatment, it is necessary to use appointment time effi­ciently.  Except in unusual circumstances, we require 24 HOURS’ notice in canceling an appointment in order that we may reschedule another client for that time.  If you do not keep a scheduled appointment and have not canceled prior to 24 hours, you will be charged $25.00 for that appointment.

If you have further questions concerning your fee or circumstances, please contact the Business Manager or Executive Director.

Board of Directors

MENTAL HEALTH CENTER OF NORTH IOWA, INC.  

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Release Information On Fee Agreement

Mental Health Center of North Iowa

235 South Eisenhower Avenue

Mason City , Iowa 50401-1562

Phone (641)  424-2075     Fax (641) 424- 9555

Specific Release for Routine Filing of Information and Use of Third-Party Payors

I understand that I will be using a third party to assist in the payment of services used through the Mental Health Center of North Iowa.  A third-party includes Medicare, Medicaid, Blue Cross/Blue Shield, insurance companies, federal or state grants and county of residence or legal settlement.  The Center may draw on my county’s Central Point of Coordination as a third party for resources to help defray the costs of services that I or a designated third party are unable to provide payment.  The county is considered a third party and payor of last resort.  I understand that, as part of using a third-party payor, information will be sent that includes my name, age, ID numbers, dates of service, diagnosis, therapeutic procedures, costs of service and, when necessary, related service information to authorize, justify, continue or coordinate services and payment.  If information exceeds that minimally necessary, the Mental Health Center of North Iowa will seek my further authorization.  This is often associated with managed mental health care services offered through a third party.

Managed Mental Health Care for Counties and Title XIX

I understand that the State of Iowa has developed managed mental health care arrangements for the provision of mental health services I receive as a benefit holder of Title XIX.  By agreeing to participate in Title XIX, the managed care conditions established by Iowa with their managed care organization will apply in our work together at the Mental Health Center .  The Mental Health Center will not bill me for services covered and approved by Title XIX.  The Mental Health Center may use county resources to assist in covering the cost of services that may not otherwise be covered by Title XIX and will do so only as a funder of last resort.

I understand that managed mental health conditions will also apply whenever the County assists in the payment of any service.

SPECIAL CONSENT PROVISIONS FOR CHILDREN AND YOUTH UNDER THE AGE OF 18

As the custodial parent or guardian for _____________________, I authorize the Mental Health Center of North Iowa to perform diagnostic and treatment services.

 ADDITIONAL INFORMATION

As part of my visit to the Center, I have received information regarding charges and the fee agreement, as well as services offered through the Center.

I understand that my informed written consent will be secured for the release of any information to others and a release of information form will be available for this purpose and that a copy of this release is available to me.

I understand that information regarding my care may be shared internally to assure effective service.

I understand that the Center’s professional staff are mandatory reporters of child abuse/neglect and are required under law to make reports of all situations where there is reason to believe such a condition may exist.

I understand that the Center will not be bound by confidentiality in any life threatening condition that might apply to me or others.

I understand that I may have a copy of the orientation to the Mental Health Center of North Iowa that explains services and my rights and responsibilities.

I understand that I may have a copy of the Center’s Privacy Notice under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which explains how the Center will use protected health information for treatment, payment and health care operations, as well as my rights under HIPAA.

 CONSENT TO PARTICIPATE

I consent to participate in treatment, assessment and services of the Mental Health Center of North Iowa.

Signature:______________________________    Date:  __________

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Authorization For Release of Information

Mental Health Center of North Iowa

235 South Eisenhower Avenue

Mason City , Iowa 50401-1562

Phone (641)  424-2075     Fax (641) 424- 9555

 I understand that:

·    I am authorizing the Mental Health Center of North Iowa and those identified above to release and exchange information.

·  Unless I otherwise note, this authorization shall be reciprocal and will allow for information to be exchanged by oral, written and electronic means __________________.

·    This authorization will remain valid until: _____________________________________  

·    My written notice to the Mental Health Center of North Iowa at the address above will revoke this authorization, but will not cover information released prior to the revocation.

·    This authorization shall not be a condition for services, unless it is required solely as part of the referral I have agreed to with the third party listed above to create protected health information.

·    I have the right to access and copy my health information.

·    I have the right to request to restrict disclosures of and to request to amend my health information.

·    I have the right to receive a copy of the Mental Health Center of North Iowa’s Notice of Privacy Practices.

INFORMATION BEING FORWARDED TO OTHERS SHALL BE SAFEGUARDED BY FEDERAL AND STATE LAW INCLUDING RESTRICTIONS ON THE FURTHER RELEASE BY THE RECEIVER OF THE INFORMATION RELEASED UNDER THIS AUTHORIZATION. 

I UNDERSTAND THAT THE MENTAL HEALTH CENTER OF NORTH IOWA CANNOT ASSURE THAT THE RECIPIENT OF THE INFORMATION AUTHORIZED TO BE RELEASED WILL NOT REDISCLOSE THE RECEIVED INFORMATION AND THAT PARTY MAY NOT BE SUBJECT TO FEDERAL AND STATE LAWS REGARDING THE PRIVACY OF HEALTH INFORMATION.