- 1. When medically necessary among doctors, technicians, and other employees of Lincoln Trail Behavioral Health System and with other healthcare providers actively involved in your care.
- 2. When required for public health issues such as workman’s compensation.
- 3. Information that is necessary in order to file insurance claims and successfully complete all billing and collection procedures.
- 4. When required by any state or federal law.
- 5. When used for clerical purposes including appointment reminders, research and any necessary chart audits.
- 6. When required for any specialized government or military functions including active personnel, reservist, veterans, and discharged members of the military service. Also, for any person confined to a correctional institution or under any law enforcement supervision.
- 7. When information is needed to protect the safety of our staff.
You as the patient have rights to your private Health Information, including:
1. The right to review your records or receive a copy of your records at any time by signing a written release. However, under certain rare circumstances we have the right to deny your request. If needed, interpretation of the records will be provided. We are required to respond to your request for records within 30-60 days.
2. The right to request information of any party that has requested information pertaining to your private health information. You also have the right to restrict certain parties from receiving your medical information, although Lincoln Trail Behavioral Health System is not required to agree to the restriction.
3. The right to receive confidential communication regarding your private health information.
4. The right to revoke this consent in writing, however, this will not affect any information already disclosed.
We as Lincoln Trail Behavioral Health System have the responsibility to:
- 1. Make each patient aware of the Privacy Notice.
- 2. At any time make the necessary changes to the Privacy Notice that are required by law.
If you as the patient feel your privacy has been violated you have the right to complain by filing a written complaint with our Privacy Officer or with the Secretary of Health and Human Services in Washington, D.C. To contact the Privacy Officer for Lincoln Trail Behavioral Health System write to 3909 South Wilson Road, Radcliff, KY 40160, attention Privacy Officer and/or phone 270-351-9444, ext. 318. You can also fax a confidential message to the Privacy Officer at 270-351-8075.
I, ______________________________________, hereby authorize Lincoln Trail Behavioral Health System to release private health information on my behalf to the following person(s):
___________________________________ _________________________________
___________________________________ _________________________________
___________________________________ _________________________________
______________________________________________________ ________________
Patient Signature/Legal Guardian Date
______________________________________________________ ________________
Lincoln Trail Behavioral Health System Representative Date
