Achievement Services Privacy Policy





Effective Date April 14, 2003


This Notice describes how health and service information about you may be used and disclosed and how you can get access to this information.  You should read this Notice or have someone explain it to you before signing the Acknowledgment.  Please review it carefully.

1. Our Duty to Safeguard Your PHI.


Individually identifiable information about your past, present, or future physical or mental health or condition, the provision of health care to you, or the payment for the health care is considered “Protected Health Information”, or “PHI”.  We are required to extend certain protections to your PHI, and to give you this notice about our privacy practices that explains how, when and why we use or disclose your PHI.  Under special circumstances, we will disclose only the minimum necessary PHI to accomplish the purpose for use or disclosure.

We are required to follow the privacy practices described in this Notice, although we reserve the right to change our privacy practices and the terms of this Notice at any time.  The new notice provisions will be effective for all PHI we maintain.  If our privacy practices change, you may request a paper copy of the notice from the Privacy Officer, whose address appears below.

2. How We May Use and Disclose Your PHI.


Achievement Services for Northeast Kansas, Inc. collects PHI about you and stores it in files and/or on the computer, which we call a “record”.  Although the PHI is yours, the record is the property of Achievement Services for Northeast Kansas, Inc.  Achievement Services for Northeast Kansas, Inc. protects the privacy of your PHI, but the law permits us to use or disclose your PHI for the following purposes:

    A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations:


The following are examples of the types of uses and disclosures of your PHI that Achievement Services for Northeast Kansas, Inc. is permitted to make once you have signed our Acknowledgment form.  These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by us once you have signed the Acknowledgment.


  • For Treatment:  We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with staff members, volunteers, interns, and third parties that have authorization or your permission to have access to your PHI.  For example, your PHI may be shared among members of your service planning team, your physician, laboratories or specialists involved with your treatment.


  • For Payment:  We may use or disclose your PHI in order to bill and collect payment for our services.  For example, we may release portions of your PHI to Medicaid agencies, a private insurance plan, or other state offices to get paid for services delivered to you.  We may also release your eligibility for publicly funded services.


  • For Health Care Operations:  We may use or disclose your PHI in the course of day to day operations of Achievement Services for Northeast Kansas, Inc. For example, we may use your PHI in evaluating the quality of services provided.  We may also disclose your PHI to third party “business associates”, including such parties as our attorney or our accountant for audit purposes. Our business associates are required to sign an agreement stating that they will keep all PHI confidential.


    B. Other Uses and Disclosures Not Requiring Authorization:  The law provides that we may use or disclose your PHI without authorization in the following circumstances:


  • Reminders and Information:  We may contact you to provide appointment reminders or information about service alternatives or other health-related benefits and services that may be of interest to you.


  • When Required by Law:  We may use or disclose your PHI to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, as required by law, of any such circumstances or disclosures.  For example, we may disclose PHI when a law requires that we report information about suspected abuse or neglect.  We must also disclose PHI to authorize who monitors compliance with these privacy requirements.


  • Legal Proceeding:  We may disclose PHI in the course of any judicial or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.


  • Law enforcement:  We may also disclose PHI for law enforcement purposes.  These law enforcement purposes include (1) legal processes required by law, (2) limited information requests for identification and location purposes, (3) information pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) the possibility that a crime has occurred at your residence, and (6) medical emergency (not in your residence) where it is likely that a crime has occurred.


  • For Public Health Activities:  We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.


  • For Health Oversight Activities:  We may disclose PHI to agencies responsible for audits, investigations, inspections, licensure, accreditation, and other oversight activities.  We may also disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products: to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.


  • Relating to Decedents:  We may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.  We may disclose such information in reasonable anticipation of death.


  • To Avert Threat to Health or Safety:  In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.


  • For Specific Governmental Functions:  We may disclose PHI to military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons, including the provision of protective services to the President or others so legally authorized.


  • Workers’ Compensation:  We may disclose your PHI as necessary to comply with workers’ compensation.


  • Fundraising: Achievement Services for Northeast Kansas, Inc. may contact you to raise funds for the Agency.  As part of these fundraising activities, certain PHI may be disclosed to a “business associate” or to a foundation, association or corporation, closely affiliated with Achievement Services for Northeast Kansas, Inc.  You have the right to refuse to participate in these activities if you so choose.


C. Uses and Disclosures Requiring That You Have an Opportunity to Object:

We may use and disclose your PHI in the following described instances, for which you have the opportunity to agree or object to the use or disclosure of all or part of your PHI.  If you are not present or able to agree or object to the use or disclosure of the PHI, then Achievement Services for Northeast Kansas, Inc. may, using professional judgment, determine whether the disclosure is in your best interest.  In this case, only the PHI that is relevant to your health care will be disclosed.


  • Personal Involvement:  We may disclose to a member of your family, a relative, a close friend, or any other person you identify your PHI that directly relates to that person’s involvement in your health care.


  • Notifications:  We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your location, general condition or death.


  • Disaster relief:  We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts.


3. When We May Not Use or Disclose Your PHI Without Authorization:

In all instances not otherwise permitted by this Notice to release your PHI, we will ask you to sign an authorization form required by law.  Your authorization can be revoked in writing at any time to stop future uses or disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

 4. Your Rights Regarding Your PHI:

You have the following rights relating to your PHI:

     A. To Request Restrictions or Uses or Disclosures:  You have the right to ask that we limit how we use or disclose your PHI for treatment, payment or health care operations.  You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  We will consider your request, but are not legally bound to agree with the restriction.

    B. To Choose How We Contact You:  You have the right to ask that we send you information at an alternative address or by an alternative means.  We must agree to your request as long as it is reasonably easy for us to do so.  For example, in most cases it will be impossible for us to hand deliver information or to overnight it via Federal Express or a similar mailing company.

    C. To Inspect and Copy:  You may inspect and obtain a copy of your PHI that is contained in a “designated record set” for as long as we maintain the PHI.  A “designated record set” contains medical and billing records and any other records that Achievement Services for Northeast Kansas, Inc. uses for making decisions concerning you.  Under law, however, you may not inspect or copy the following:  Psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to law that prohibits access to PHI.  If you want copies of your PHI, a charge for copying may be imposed, but may be waived depending on your circumstances.  You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

     D. To Request Amendment of Your PHI:  You have a right to request that we amend your PHI if it is incomplete or incorrect.  We are not required to change your PHI.  If we cannot amend your PHI in accordance with your request, we will provide you with information about the denial and how you can disagree with the denial.

     E. To Find Out What Disclosures Have Been Made:  You have a right to receive a report of when,` to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for treatment, payment and operations.  The report also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April 14, 2003.  Subject to the foregoing, your request can relate to disclosures going as far back as six years.  We will respond to your request for a report within 60 days of receiving the request.  There will be no charge for one such report made each year.  There may be a reasonable charge for more frequent reports.

     F. To Receive This Notice:  You have the right to receive a paper copy of this Notice of Privacy Practices.


5. How to Complain About Our Privacy Practices:

If you think we may have violated your privacy rights, or your disagree with a decision we made about access to your PHI, including any decisions about your rights, your may file a complaint verbally or in writing with our Privacy Officer, whose address appears below.  You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services.  We will take no retaliatory action against you if you make a complaint.

6. Privacy Officer to Contact for Information or to Submit a Complaint:

If you have questions about this Notice or wish to make a complaint about our privacy practices, please contact: Dave Hager, Privacy Officer, Achievement Services for Northeast Kansas, Inc. 215 North 5th Street, PO Box 186, Atchison Kansas 66002, 913-367-2432.


 NOTICE OF PRIVACY PRACTICES Effective Date April 14, 2003



Note:  This document is a discussion aid to help explain the Notice of Privacy Practices to an individual who has reading difficulties.  It is not a substitute for the full Notice.


We will use your information in the following way:

  • For planning for, and providing services to you (treatment).
  • To get payment for services provided to you, for example when we bill the State (payment).
  • To meet the requirements for running our agency, for example when we conduct a review of your file to make sure that it is complete, has the required forms, etc. (operations).


Other examples are:

  • To send you a reminder of an appointment or other health information that might be of interest to you (i.e. a place where you could buy your medication at a more reasonable cost.
  • When we are required to by law (i.e. in cases of abuse), or by a public health authority (i.e. required reporting of some disease), to avoid a threat of health and safety (i.e. if a person is dangerous), or if required by another government agency (i.e. for eligibility for benefits like workers’ compensation).
  • If required by a court, or a government administrative agency as part of a legal proceeding.
  • If required by the Police, or other law enforcement authority.
  • For oversight activities, such as licensing reviews or investigations, and other monitoring that help us provide safe, high quality services and surroundings for you.
  • In case you should die, we would need to share information about you to people handling the arrangements.
  • We may ask you to participate in fund-raising activities for the organization.  You do not have to participate if you do not want to.
  • If you have health insurance, we may share information with your health plan.


We will give you a chance to agree or object when:

  • We need to contact your family or other person responsible for your care about your location or general condition, for example if you are hurt or sick.  If we can, we will ask you if this is okay.  If you are not able to give your permission, we will use our best judgment in contacting your family.


For all other uses of your health information (except those we have already talked about), we need your permission.

  • This permission is known as an authorization
  • You can change your mind and withdraw your authorization at any time.
  • We will ask you to sign a paper to do this.


Your rights regarding your health information:

  • You can ask that we not share certain information.  Sometimes we may not be able to do this.  If this happens, we will explain why.
  • If you want us to contact you at a certain location or communicate with you in a certain way (for example, to explain documents to you), we will try to do this.
  • You can see your health information and have copies, if you wish.  We may need to charge you for the copies.
  • You can ask that we change certain information in your file, but we might not be able to do this.
  • You can have a list about information that has been shared with individuals outside our agency, except for treatment, payment, and operations that we discussed earlier.
  • You can have a paper copy of the Privacy Notice.
  • Under law you may not inspect or copy the following:  Psychotherapy notes; information for use in a civil, criminal, or administrative proceeding; and PHI that cannot be disclosed by law.


You can complain if you think we have violated your privacy rights or if you don’t agree with a decision we made about your health information:

  • Call or write to : Dave Hager, Privacy Officer, Achievement Services for Northeast Kansas, Inc. 215 North 5th Street, PO Box 186, Atchison, Kansas 66002, 913-367-2432.
  • You may also write to the Secretary of the U.S. Department of Health and Human Services.
  • No one will be mad and nothing will happen to you if you complain.