Siouxland Mental Health Center Privacy Notice
Siouxland Mental Health Center is committed to ensuring your privacy. Please read carefully.


Siouxland Mental Health Center 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. This notice further explains these policies and the exceptions that by law we will observe in the disclosure of personal health information.

    1. How we may use and disclose protected health information Siouxland Mental Health Center uses and discloses health information in each category listed below which we give examples 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 and, under limited conditions without your further authorization in order to provide your treatment and treatment related services. Without further authorization we may also use and disclose your health information to coordinate and mange your health care and related services. For example we may disclose information to a managed care coordinator working for your health insurance or managed care company. Staff may discuss your care in an internal case conference. Unless you object, we do not seek further authorization from you to release the minimum necessary information to assist you with laboratories, pharmacies and to those you involve in helping to arrange appointments and travel. Unless further exceptions are noted by law and noted in the privacy notice, the Center will release information for treatment only on the basis of your authorization.
        1. Use and disclosure for Payment: We will secure your written consent to release information for payment. We may use or disclose you health information without your further authorization so that treatment and services you receive are billed to, and payment is collected from your health plan or third party payer or the County. 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 plans 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.
        1. Use and disclosure for Health Care Operations: We may use and disclose health information about you without your further authorization for our 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 the providers, training in clinical functions, licensing, and accreditation, planning and program development. We may use health care information by de-identifying it do data can be used for planning and service delivery. 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.


    1. Uses and Disclosures that may be made without your further authorization but which you have the right to ObjectSiouxland Mental Health Center will seek your authorization to release information with the exceptions noted here 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/guarantor who may call to arrange for an appointment, a family member who calls to arrange transportation, or a family member who is assisting you with 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.
    1. Uses and Disclosures without your consent or authorization Federal and state law set conditions under which Siouxland Mental Health Center may release your health information with out either your consent or authorization, which 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
      • Responding to dangerousness to self or others
      • To correctional officers for the purpose of treatment or safety
      • Compliance with laws related to workers compensation
      • Health oversight activities including accreditation and regulatory reviews
      • Professional to parents, children, spouse or siblings of and adult with chronic mental health
      • To law enforcement when there has been a gunshot wound, where a crime has occurred with us, or to help in an emergency where there is dangerousness to self/others.
    1. Uses and Disclosures of your health information with your permission The Center initiates and continues treatment based on your consent, which you provide in writing to us and which if further acknowledged in this privacy notice. Siouxland Mental Health Center treats the personal information you give us as confidential. Unless it meets a condition noted elsewhere in this privacy notice, the Center will require your further permission and authorization to release and to exchange information. 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 in a time limit.The Center maintains a release of information form for the expressed purpose of securing your authorization in writing. The release is allowing us to release and to exchange information with the party you designate unless you prefer to 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 revoke this authorization at any time and we will not make any further authorizations. The revoking must be done in writing and only covers from the date the revocation becomes effective.
  1. Siouxland Mental Health Center responsibilities with this Privacy Notice The Center agrees to abide by the terms of its Privacy Notice currently in effect. This Privacy Notice was developed on February 25, 2003 and goes into effect on April 14, 2003. Siouxland Mental Health Center reserves the right to make changes to the privacy notice and will post any changes in advance of their effective date. Changes made by Siouxland Mental Health Center will be reflected in a revised privacy notice that will be available to you.
    Siouxland Mental Health Center
    Consumer Acknowledgement and Consent
    I have received an orientation to the Center which has explain the policies and procedures and I consent to Siouxland Mental Health Center privacy notice, a copy of which has also been made available to me.Consumer Name: ___________________________________

    Date: _____________________

    Witness: _______________________________

    Date: _____________________