This notice describes how Petty Creek Ranch may use and disclose your child’s personal health information and how you and/or your child can obtain access to this information.

PLEASE REVIEW THIS CAREFULLY

Petty Creek Ranch creates records of health information to provide quality care and comply with legal requirements. Petty Creek Ranch understands your child’s health information is personal and private, and commits to safeguarding it to the extent reasonably possible. The law requires Petty Creek Ranch to keep your child’s health information private and to provide you this notice of our legal duties and privacy practices. The law also requires Petty Creek Ranch follow the terms of this notice.

This notice outlines the limits on how Petty Creek Ranch will handle your child’s health information. Under federal law, Petty Creek Ranch must provide a copy of this when your child receives services from Petty Creek Ranch. Petty Creek Ranch reserves the right to change practices and make new provisions effective for all health information it maintains. You may request an updated copy of this form at any time.

Generally, as otherwise specified below, Petty Creek Ranch may use and disclose the information as allowed by state and federal law:

For Treatment: Petty Creek Ranch uses and discloses health information to provide related services for child: Petty Creek Ranch employees may record your child’s health information and they may share such information with other Petty Creek Ranch employees.

In emergencies, Petty Creek Ranch may use or disclose your child’s health information to provide treatment. Petty Creek Ranch will make its best effort to obtain your permission to use or disclose your child’s health information as soon as reasonably practical.

For payment: Petty Creek Ranch may bill you or third parties. Information on or accompanying these bills may identify you, as well as assessment, and services performs.

For Healthcare Operations: Petty Creek Ranch may use health information to assess the care and outcomes in your child’s case to improve our services, and in administrative processes such as for auditing financial date.

On a limited basis, Petty Creek Ranch may use and disclose health information only with your permission as required by state and federal law:

• For mental health records
• For substance use disorder records

In certain cases, Petty Creek Ranch may use and disclose health information only if it informs you in advance and provides an opportunity to agree, object, as required by state and federal law.

• To individuals assisting with your child’s treatment or payment.
• To assist with disaster relief to notify your family about your child.

In specific cases, Petty Creek Ranch may use and disclose the following health information without your permission and without providing you the opportunity to agree or object:

• As required by law: court order or subpoena FOR PUBLIC ACTIVITIES Preventing or controlling disease, injury or disability Reporting death or birth
• For mandated reporting of abuse or neglect of children, elders and dependent adults, or domestic violence. Reporting reactions to medications or problems with products
• Notifying people of recalls of products they may use
• Notifying a person exposed to or at risk to contract or spread a disease or condition.
• For health oversight activities necessary for the government to monitor the healthcare system, government programs and compliance with civil right laws.
• To the minimum extent necessary to comply with judicial and administrative proceedings when    compelled by court order, in response to subpoena, discovery request or other lawful process as allowed by law.

To identify or locate a suspect, fugitive, material witness, or missing person

About the victim of a crime if under certain limited circumstances, we are unable to obtain the person’s agreement About a death we believe may be the result of criminal conduct

About criminal conduct at the program location In emergency circumstances to report

To coroners, medical examiners and funeral directors as necessary to carry out their duties

For public health research in compliance with strict conditions approved and monitored by an institutional review board To authorized federal officials and law enforcement custodial situations, inmates of correctional institutions or in custody of law enforcement official To determine your eligibility for or enroll you in government health programs.

Petty Creek Ranch will not disclose your health information for marketing, fundraising or other reasons not listed above.

With regards to health information, Petty Creek Ranch recognizes and commits to safeguarding your child’s:

Rights to request restrictions on certain use and disclosure. You have the right to request restrictions or limitations on the health information. Petty Creek Ranch uses or discloses for treatment or payment though the law does not require Petty Creek Ranch to agree to request. If Petty Creek Ranch agrees, it will comply to provide emergency treatment. Requests must be in writing and state: the information you want to limit, whether to limit use, disclosure or both, and to whom limits apply. For instance, you may ask not to disclose information to your spouse or parents.

Right to confidential communications. You have the right to ask Petty Creek Ranch to communicate with you in a certain way or a certain location.

Right to inspect and copy record. You have the right to inspect and obtain copies of your health information. Request must be in writing. Petty Creek Ranch may charge you a fee for the cost of fulfilling your request (10 cents a page). Petty Creek Ranch may deny requests to inspect or copy psychotherapy notes, mental health records, or material for legal proceedings. You may ask to review the denial by another health care professional chosen by Petty Creek Ranch.

Right to amend health records. If information Petty Creek Ranch has about you is incorrect or incomplete, you may ask to amend it. Requests must be in writing, and provide a reason supporting your request. Petty Creek Ranch may deny your request if it is not in writing or does not include a reason supporting it. Petty Creek Ranch may deny requests if the information was not created by Petty Creek Ranch, Health information not kept by Petty Creek Ranch.

Right to accounting of certain disclosures. You have the right to ask for the listing of the last six years of disclosures of your health information since your admission date, not pertaining to treatment, payment or health care operations. Request must be in writing, Right to obtain a paper copy of the notice of privacy practices upon request

Right to file complaints without fear of retaliation. Under law, Petty Creek Ranch cannot penalize you for filing a complaint. If you believe Petty Creek Ranch violated your privacy rights, you may file a complaint with Michael Morso, the CEO of Petty Creek Ranch, or with the U.S. Secretary of Health and Human Services.

Petty Creek Ranch, LLC 

Michael Morso

P.O Box 289 Alberton, MT 59820

PHONE: (406) 722-3226

FAX: (406) 722-3253

or

50 United National Plaza, Room 322 

San Francisco Ca 94102 

Tel: 415-437-8310

TDD: 415-437-8311

Fax: 415-437-8329