HIPAA Privacy Notice

HIPAA Privacy Notice



Effective Date: August 1, 2022



If you have any questions about this Notice, please contact:

Privacy Officer – Crawford Marion Alcohol, Drug Addiction & Mental Health Board

105 Washington Square, Suite 203, Bucyrus, OH 44820 Phone: 740-387-8531



At the Crawford Marion ADAMH Board, we are committed to protecting your health information and safeguarding that information against unauthorized use or disclosure. This Notice will tell you how we may use and disclose your health information.  It also describes your rights and the obligations we have regarding the use and disclosure of your health information.

We are required by law to: 1) maintain and protect the privacy of your health information; 2) provide you with this Notice of our legal duties and privacy practices with respect to your health information; 3) abide by the terms and practices described in this Notice; and 4) notify you if there is a breach of your unsecured health information.



When you receive services paid for in full or part by the Board, we receive health information about you.  The information we receive may include, for example, eligibility, claims and payment information.  We create a record of your enrollment in Ohio’s public mental health and addiction services system and maintain that record and records related to the services you receive in the public system and payment for those services.  We may also receive information from your treatment provider related to your diagnosis, treatment, progress in recovery, and any major unexpected emergencies or crises you may experience to help the Board plan for and improve the quality of services paid for with Board funds.

We use and disclose information about your health for several reasons.  We may receive, use or share that health information for such activities as payment for services provided to you, conducting our internal health care operations, communicating with your healthcare providers about your treatment, and for other purposes permitted or required by law.    The following are examples of the types of uses and disclosures of your personal information that we are permitted to make: 

Payment – We may use or disclose your health for payment activities such as confirming your eligibility, managing your claims, utilization review activities and processing health care data.

Health Care Operations – We may use your health information to train staff, manage costs, conduct quality review activities, perform required business duties, and improve our services and business operations.

Treatment – We do not provide treatment, but we may share your personal health information with your health care providers, including but not limited to those with whom we have a current agreement for services, to assist in coordinating your care.

Other Uses and Disclosures – We may also use or disclose your personal health information for the following reasons as permitted or required by applicable law:  To alert proper authorities if we reasonably believe that you may be a victim of abuse, neglect, domestic violence or other crimes; to reduce or prevent threats to public health and safety; for health oversight activities such as evaluations, investigations, audits, and inspections; to governmental agencies that monitor your services; for lawsuits and similar proceedings; for public health purposes such as to prevent the spread of a communicable disease; for certain approved research purposes; for law enforcement reasons if required by law or in regards to a crime or suspect; to correctional institutions in regards to inmates; to coroners, medical examiners and funeral directors (for decedents), as required by law; for organ and tissue donation; for specialized government functions such as military and veterans activities, national security and intelligence purposes, and protection of the President; for Workers’ Compensation purposes; for the management and coordination of public benefits programs; to respond to requests from the U.S. Department of Health and Human Services; and for us to receive assistance from business associates that have signed an agreement requiring them to maintain the confidentiality of your health information.  Also, if you have a guardian or a power of attorney, we are permitted to provide health information to your guardian or attorney in fact.

Fundraising Activities – We may also use your health information to contact you to raise money as part of fundraising efforts, such as for assistance in passing levies.  You have the right to opt-out of receiving such communications by notifying us, at the address below, that you do not wish to be contacted for such purposes.

Uses and Disclosures That Require Your Written Permission

We are prohibited from selling your personal information, such as to a company that wants your information in order to contact you about their services, without your written permission.

We are prohibited from using or disclosing your personal information for marketing purposes, such as to promote our services, without your written permission.

All other uses and disclosures of your health information not described in this Notice will be made only with your written permission.  If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written permission.  We are unable to take back any disclosures we have already made with your prior permission.

Prohibited Uses and Disclosures of Your Health Information

If we use or disclose your health information for underwriting purposes, we are prohibited from using and disclosing any genetic information in your health information for such purposes.


If any state or federal privacy laws require us to provide you with more privacy protections than those described in this Notice, then we must also follow that law in addition to HIPAA.  For example, drug and alcohol treatment records generally receive greater protections under federal law.


You have the following rights regarding your health information:

  • Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for purposes of treatment, payment, health care operations and informing individuals involved in your care about your care or payment for that care. We will consider all requests for restrictions carefully but are not required to agree to any requested restrictions.  We cannot agree to limit uses or disclosures that are required by law.*
  • Right to Request Confidential Communications. You have the right to request that when we need to communicate with you about health matters, we do so in a certain way or at a certain location.  For example, you can request that we only contact you by mail or at a certain phone number.
  • Right to Access, Inspect and Copy. You have the right to request access to certain health information we have about you.  Under certain circumstances, we may deny access to that information such as if the information is the subject of a lawsuit or legal claim or if the release of the information may present a danger to you or someone else.  We may charge a reasonable fee to copy information for you. *
  • Right to Amend. You have the right to request corrections or additions to certain health information we have about you.  You must provide us with your reasons for requesting the change.*
  • Right to An Accounting of Disclosures. You have the right to request an accounting of the disclosures we make of your health information, except for those made with your permission and those related to treatment, payment, our health care operations, and certain other purposes, such as if the information is the subject of a lawsuit or legal claim or if release of the information may present a danger to you or someone else. Your request must include a timeframe for the accounting, which must be within the six years prior to your request. The first accounting is free, but a fee will apply if more than one request is made in a 12-month period.*
  • Right to be Notified in the Event of a Breach of Confidentiality. If your protected health information has been used or released inappropriately or accidentally, you have a right to be notified of that release.
  • Right to a Paper Copy of Notice. You have the right to receive a paper copy of this Notice.  This Notice is also available at our web site mcadamh.com but you may obtain a paper copy by contacting the Board Office.

To exercise any of the rights described in this paragraph, please contact the Board Privacy Officer at the following address or phone number:

Privacy Officer, 105 Washington Square, Suite 203, Bucyrus, OH 44820, Phone: 740-387-8531


* To exercise rights marked with a star (*), your request must be made in writing.

Please contact us if you need assistance.


We reserve the right to change this Notice at any time.  We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of our current Notice at our office and on our website at: www.mcadamh.com.  In addition, each time there is a change to our Notice, you will receive information by mail at the last known address we have on file for you about the revised Notice and how you can obtain a copy of it.  The effective date of each Notice is listed on the first page in the top center.



If you believe your privacy rights have been violated, you may file a written complaint with the Board or with the Secretary of the Department of Health and Human Services.  To file a complaint with the Board, contact the Privacy Officer at the address above. You will not be retaliated against for filing a complaint.  If you wish to file a complaint with the Secretary you may send the complaint to:

Office for Civil Rights
U.S. Department of Health and Human Services

Attn: Regional Manager
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

(further information about filing options can be found at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html)

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