Julian F. Keith Alcohol & Drug Abuse Treatment CenterBlack Mountain, NC

Revised Date: April 1, 2007









Responsibilities of Julian F. Keith Alcohol & Drug Abuse Treatment Center

JFK-ADATC is required by state and federal law to protect the privacy of your health information that may identify you.  This health information includes mental health, developmental disability and/or substance abuse services that are provided to you, payment for those health care services, or other health care operations provided on your behalf.   


This agency is required by law to inform you of our legal duties and privacy practices with respect to your health information through this Notice of Privacy Practices.  This Notice describes the ways we may share your past, present and future health information, ensuring that we use and/or disclose this information only as we have described in this Notice.  We do, however, reserve the right to change our privacy practices and the terms of this Notice, and to make the new Notice provisions effective for all health information we maintain.   Any changes to this Notice will be posted at our facility and on our agency web site at  Copies of any revised Notices will be available to you upon request.


If at any time, you have questions or concerns about the information in this Notice or about our agency’s privacy policies, procedures and practices, you may contact our agency Privacy Official at 828/257-6211.


Use and Disclosure of Health Information Without Your Authorization

Treatment: JFK-ADATC may use your health information, as needed, in order to provide, coordinate or manage your health care and related services.  This includes sharing your health information with other health care providers within this agency.  (Example:  Your treatment team, composed of staff such as doctors, nurses, psychologists, counselors, social workers, rehabilitation therapists, educators will be involved in your treatment planning and discharge planning.)


We will disclose your health information outside of this agency only with your consent or when otherwise allowed under state or federal law.  (Example: We may disclose your health information to other mental health facilities or


professionals (i.e., community based area mental health, developmental disabilities and substance abuse services program or psychiatric service in order to coordinate your care.) We will not refer you to another person for treatment and rehabilitation without your authorization. (Example: We may share your health information with a health care provider for emergency services.  Example: We may disclose your health information to independent laboratories for completion of testing [i.e., x-rays, urine or blood analysis, etc] not available at our facility.)


Payment for Services: The treatment provided to you will be shared with our agency’s billing department so that you can be billed for services rendered.  We may also share your health information with agency staff who review services provided to you to make certain you have received appropriate care and treatment.  We will not disclose your health information outside of this agency for billing purposes without your consent. (Example:  Our billing department will collect insurance and other financial information from you at the time of admission along with written consent from you to file for insurance benefits.)


Health Care Operations: JFK-ADATC may use or disclose your health information in performing a variety of business activities that we call “health care operations”.  Some examples of how we may use or disclose your health information for health care operations include the following:

·         Reviewing the care you receive here and evaluating the performance of your treatment team to ensure you have received quality care.

·         Reviewing and evaluating the skills, qualifications and performance of health care providers who are taking care of you.

·         Providing training programs for agency staff, students interns and volunteers.

·         Cooperating with outside organizations that review and determine the quality of care that you receive.

·         Provide information to professional organizations that evaluate, certify or license health care providers, staff or facilities.



·         Allowing our agency attorney to use your health information when representing this agency in legal matters.

·         Resolving grievances within our agency.

·         Providing information to your internal client advocate who is available to represent your interests.


Other Circumstances: JFK-ADATC may disclose your health information for those circumstances that have been determined to be so important that your authorization may not be required.  Prior to disclosing your health information, we will evaluate each request to ensure that only necessary information will be disclosed.  Those circumstances include disclosures that are:

·         Required by law;

·         For public health activities.  (Example: we may disclose health information to public health authorities if you have a communicable disease and we have reason to believe, based upon information provided to us, that there is a public health risk such as evidence of your noncompliance with your treatment plan.)  If you suffer from a communicable disease such as tuberculosis or HIV/AIDS information about your disease will be treated as confidential.  Other than circumstances described to you in other sections of this Notice, we will not release any information about your communicable disease except as required to protect public health or the spread of a disease or at the request of the State or Local Health Director;

·         Regarding child abuse or neglect.

·         For health oversight activities such as JCAHO and CMS accreditation;

·         For Audit and Evaluation. To conduct outcome studies, utilizing the North Carolina Treatment Outcomes and Program Performance System (NC-TOPPS) tool, for monitoring and planning for improved patient services.

·         Relating to death such as disclosure to a funeral director;

·         Relating to donation of organs or tissue;

·         To avert a serious threat to the health or safety of a person or the public;

·         Relating to specialized government activities such as national security;

·         When a crime has been committed on our premises or against our personnel;

·         To correctional institutions or other law enforcement officials when you are in their custody; and

·         Related to medical research.


Contacting You

JFK-ADATC may use your health information to contact you for the following reasons.

·         To gather feedback regarding your ongoing recovery efforts. (Example: This agency may contact you through a telephone call about an whether you kept your aftercare appointments or whether you are participating in any self help groups);



Disclosure of Your Health Information That Allows You An Opportunity To Object

There are certain circumstances where we may disclose your health information and you have an opportunity to object.  Such circumstances include:


·         Disclosure to public or private agencies providing disaster relief.  (Example: We may share your health information with the American Red Cross following a major disaster such as a flood.)


If you would like to object to our disclosure about your health information in the situation listed above, please contact our agency Privacy Official listed in this Notice for consideration of your objection.



Disclosure of Your Health Information That Requires Your Authorization

JFK-ADATC will not disclose your health information without your authorization except as allowed or required by state or federal law.  For all other disclosures, we will ask you to sign a written authorization allowing us to share or request your health information.  Before you sign an authorization, you will be fully informed of the exact information you are authorizing to be disclosed/requested and to/from whom the information will be disclosed/requested.


You may request that your authorization be cancelled by informing our agency Privacy Official that you do not want any additional health information about you exchanged with a particular person/agency.  You will be asked to sign and date the Authorization Revocation section of your original authorization; however, verbal authorization is acceptable. Your authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time you cancelled your authorization are legal and binding.



Your Rights Regarding Your Health Information

You have the following rights regarding your health information as created and maintained by this agency.



Right to receive a copy of this Notice 

You have the right to receive a copy of JFK-ADATC ’s Notice of Privacy Practices.  At your first treatment encounter with this agency, you will be given a copy of this Notice and asked to sign an acknowledgement that you have received it.  In the event of emergency services, you will be provided the Notice as soon as possible after emergency services have been provided.


In addition, copies of this Notice have been posted in several public areas throughout this agency, as well as on

the JFK-ADATC ’s Internet web site at You have the right to request a paper copy of this Notice at any time from our agency Admissions Officer or our agency Privacy Official.



Right to request different ways to communicate with you

You have the right to request to be contacted at a different location or by a different method.  For example, you may request all written information from this agency be sent to your work address rather than your home address.  We will agree with your request as long as it is reasonable to do so; however, your request must be made in writing and forwarded to our agency Privacy Official.


Right to request to see and copy your health information

Whether you are a competent adult or incompetent adult, you have the right to request to see and receive a copy of your health information in medical, billing and other records that are used to make decisions about you.  Your request must be in writing and forwarded to our agency Privacy Official.  You can expect a response to your request within 30 days.  If your request is approved, you may be charged a fee to cover the cost of the copy.


Instead of providing you with a full copy of your health information record, we may give you a summary or explanation of your health information, if you agree in advance to that format and to the cost of preparing such information.


Your request may be denied by your physician or a professional designated by our agency director under certain circumstances.  If we do deny your request, we

will explain our reason for doing so in writing and describe any rights you may have to request a review of our denial.  In addition, you have the right to contact our agency Privacy Official to request that a copy of your health information be sent to a physician or psychologist of your choice.


Whenever you have a personal representative who consented to your treatment, the personal representative has the same rights to request to see and copy your health information.


Right to request amendment of your health information

You have the right to request changes in your health information in medical, billing and other records used to make decisions about you.  If you believe that we have

information that is either inaccurate or incomplete, you may submit a request in writing to our agency Privacy Official

and explain your reasons for the amendment.  We must respond to your request within 30 days of receiving your

request.  If we accept your request to change your health information, we will add your amendment but will not

destroy the original record.  In addition, we will make reasonable efforts to inform others of the changes, including persons you name who have received your health information and who need the changes.


We may deny your request if:

·   The information was not created by this agency (unless you prove the creator of the information is no longer available to change the information);

·   The information is not part of the records used to make decisions about you;

·   We believe the information is correct and complete; or

·   Your request for access to the information is denied.


If we deny your request to change your health information, we will explain to you in writing the reasons for denial and describe your rights to give us a written statement disagreeing with the denial.  If you provide a written statement, the statement will become a permanent part of your record.  Whenever disclosures are made of the information in question, your written statement will be disclosed as well.


Right to request a listing of disclosures we have made

You have a right to a written list of disclosures of your health information.  The list will be maintained for at least six years for any disclosures made after April 14, 2003.  This listing will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed and the purpose of the disclosure.


This agency is not required to include the following on the list of disclosures:

·   Disclosure for your treatment;

·   Disclosure for billing and collection of payment for your treatment;

·   Disclosures related to our health care operations;

·   Disclosures that you authorized;

·   Disclosures to law enforcement when you are in their custody; or

·   Disclosures made to individuals involved in your care.






Your first request for a listing of disclosures will be provided to you free of charge.  However, if you request a listing of disclosures more than once in a 12 month

period, you may be charged a reasonable fee.  We will inform you of the cost involved and you may choose to

withdraw or modify your request at that time, before any costs are incurred.



Violation of the Federal law and regulations relative to a substance abuse program is a crime.  Suspected violations may be reported to our agency Privacy Official who will report the violation to appropriate authorities in accordance with Federal regulation.


If you believe your privacy rights have been violated by us, or if you want to file a complaint regarding our privacy practices, you may contact our agency Privacy Official.  Contact information is as follows:


Julian F. Keith – Alcohol and Drug Abuse Treatment Center

Privacy Official

201 Tabernacle Road

Black Mountain, NC 28711

828/257-6211 (phone)

828/257-6343 (FAX)



The North Carolina Department of Health and Human Services operates an information and referral service located in the Office of Citizen Services, known as CARE-LINE, which has been designated to receive and document complaints and concerns regarding your privacy.  Contact information is as follows:



2012 Mail Service Center

Raleigh, NC  27699-2012

Voice Phone: 1-800-662-7030 (Toll Free)

FAX: (919) 715-8174

TTY: (919) 733-4851



You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.  Contact information is as follows:


Office for Civil Rights

U.S. Department of Health and Human Services

Atlanta Federal Center, Suite 3B70

61 Forsyth Street, S.W.

Atlanta, GA 30303-8909

Voice Phone: (404) 562-7886

FAX: (404) 562-7881

TDD: (404) 331-2867




If you file a complaint, we will not take any action against you or change our treatment of you in any way. 



Legal References

Primary Federal and State laws and regulations that protect the privacy of your health information are listed below.


Confidentiality of Alcohol and Drug Abuse Patient Records – 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal

laws and 42 CFR Part 2 for Federal regulations.


Health Insurance Portability and Accountability Act (HIPAA), Administrative Simplification, Privacy of Individually Identifiable Health Information – 42 U.S.C. 1320d-1329d-8 and 42 U.S.C. 1320d-2(note) for Federal laws and 45 CFR Parts 160 and 164 for Federal regulations.


NC General Statutes – Chapter 122C, Article 3 (Client’s Rights and Advance Instruction), Part 1 (Client’s Rights).


NC Administrative Code – 10 NCAC 18 D (Confidentiality Rules



Julian F. Keith Alcohol and Drug Abuse Treatment Center

Black Mountain, North Carolina


Julian F. Keith Alcohol and Drug Abuse Treatment Center (herein called JFK-ADATC) must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need.  There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide.  It is the legal duty of JFK-ADATC to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.


The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within JFK-ADATC, as well as reasons why your health information could be sent to other service providers outside of this agency.


This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights.  This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures JFK-ADATC uses to protect the privacy of your health information.


Please review this document carefully and ask for clarification if you do not understand any portion. 





Patient Acknowledgement


I have received JFK-ADATC’s Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me. 


In addition, I have been informed of and received written copies of my rights, responsibilities and search and seizure practices as defined in the following policies:

A.                 Patient’s Rights;

B.                 Patient’s Responsibilities Part I and Part II; and

C.                 Search and Seizure




________________________________                                    _______________________________

Patient’s Signature                                                                                 Date


___________________________________                 _______________________________

Staff Signature                                                                                       Date


­­­­­­­­­­Form No. DMH 5-11-03 (Rev)                                                                             NOTICE TO PATIENT