HIPAA & Privacy Policy
I understand that while I am an active patient at KAV Health Group I am eligible to receive a range of services. The type and extent of services that I will receive will be determined following an initial clinical and medical assessment and discussed with me. The goal of the assessment process is to determine the best course of treatment for me.
Consent to participate in telehealth
I understand that my services may be provided through telehealth (UpDox or a similar secure videoconferencing program or phone). I will be informed of the intent to provide service via telehealth prior to the appointment and have the right to request an in-person appointment with the understanding that this may result in a change of provider. Additionally, if my provider believes that it would be beneficial for me to be seen in person, I understand that telehealth may not always be an option for me. I also waive my right to confidentiality of my medical information if others around me can hear the provider or me when I am in my appointment. I understand that if my provider is only licensed in Ohio or Kentucky that I must be in Ohio or Kentucky at time of the appointment and that I may be asked my location when I am in a telehealth appointment.
Consent to receive text messages
I agree to receive text message reminders about my appointments. I understand that depending on my contract, that I might incur charges for text messages.
Use of Medical Marijuana
In Using medical marijuana for medicinal use, I fully accept responsibility and assume any risks and side effects associated with its use. I further hold harmless and release KAV Health Group, LLC of any liability related to any risks.
Consent for General Laboratory Testing and Reporting
Laboratory testing, including but not limited to blood work, urinalysis or oral swabs may be requested. This testing may be to identify a diagnosis of HIV, Hepatitis or other bloodborne diseases as well as Tuberculosis. KAV utilizes in office “point of care” testing as well as private third-party laboratories for confirmation and definitive testing. Positive results from this lab work must be reported to the appropriate authorities. I authorize KAV Health Group and any third-party laboratory to disclose any reportable infectious disease information regarding that infectious disease to my local and state health departments for purposes of coordinating care. Only the minimum amount of protected health information needed to accomplish the intended purpose of the use is permitted for these disclosures. I understand that my substance abuse treatment records are protected under federal regulations.
Third Party Laboratories: I understand that KAV uses a third-party lab for confirmation and definitive testing as well as blood work. I authorize KAV to disclose my demographic, billing and diagnosis codes to the third-party lab for the purpose of conducting testing needed for my treatment. I also understand that I the right to request the samples be sent to a different third-party lab if I so choose or contest any results. However, any costs associated with the testing would be at my expense.
For patients enrolled in the Substance Use Disorder program or seeking treatment for their recovery
I fully accept responsibility and assume any risks and side effects associated with any controlled substance while participating in treatment with KAV Health Group, LLC. I further hold harmless and release KAV Health Group, LLC of any liability related to any risks. Potential interactions including increasing or decreasing the level of Buprenorphine in my body or, in extremely rare instances, possibly causing an abnormal heart rhythm that has the potential to be lethal. I agree that it is my responsibility to provide documentation of all medications, vitamins or supplements I am taking on at least a monthly basis.
It is important to note that receiving any medications deemed appropriate by the medical provider is contingent on you completing your scheduled Intake Assessment. Failure to complete the Intake Assessment will delay your care until it is completed.
Mental Health treatment and medications
In accordance with evidence based practices, KAV Health Group assessment and evaluation and at the recommendation of a physician may prescribe various medications to assist my treatment. Medications may be used in conjunction with psychotherapy, cognitive behavioral therapy, motivational interviewing etc. Any medications I may receive may have an adverse reaction and/or possible side effects.
I agree I shall inform any doctor who may treat me for any medical problem that I am enrolled in mental health treatment program, since the use of other medications in conjunction with any medications I may be prescribed by KAV Health Group may cause harm to me.
Medication
You are required to take medication prescribed to you and no one else’s, as it is directed with written instructions on the container. All patients must take their medication EXACTLY as prescribed/ordered. Keep medication in a safe and secure location. Theft of medication will not result in an early refill. It is important that you tell your primary care provider or any provider who writes prescriptions for you that you are receiving treatment services at KAV Health Group, LLC. State databases for monitoring controlled substances will be ran on a regular basis and, in most cases, at each medical provider visit.
DO NOT EVER SELL YOUR MEDICATION OR TRY TO BUY MEDICATION FROM SOMEONE ELSE. THIS WILL RESULT IN IMMEDIATE DISMISSAL FROM THE PROGRAM WITH NO PRESCRIPTIONS OTHER THAN COMFORT MEDS. IT COULD ALSO RESULT IN LEGAL CONSEQUENCES FOR YOU AS A PATIENT.
Confidentiality Agreement
KAV Health Group provides treatment which includes confidential clinical and medical services. KAV is legally bound by state and federal regulations for both mental health and substance abuse services. Once an appointment is made, no information can be disclosed to anyone without your written permission on a Release of Information 42 C.F.R Part 2 form. Unless otherwise required by law to report in cases of imminent danger to yourself, others, elderly or children.
KAV will not share your information with a third party without your written consent aside from obligations by the CARES ACT which is included in the consent to treat for internal use purposes. KAV staff will work diligently to protect your information provided in counseling and medical sessions. However, there are certain limitations to confidentiality. Please note the following exceptions to confidentiality:
Cases of reported or suspected abuse/neglect of children or the elderly.
Cases of potential harm to self or others
Medical emergency, information may be shared with medical personnel
On rare occasions, there could be a request by a court for your records.
Information must be shared with your insurance provider, should you choose to use insurance. This information may be seen by various employees of the insurance provider. There is also potential that certain members of your employer may see this information.
Patient Rights and Grievance
Subject to applicable state and Federal law, KAV Health Group will comply with the following patients rights established by the Ohio Department of Mental Health and Addiction Services to the extent applicable to our program:
The right to be treated with consideration and respect for personal dignity, autonomy and privacy;
The right to reasonable protection from physical, sexual or emotional abuse, neglect and inhuman treatment
The right to receive services in the least restrictive, feasible environment
The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other services, unless that service is a necessity for clear treatment reasons and requires the person’s participation
the right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency
the right to participate in the development, review and revision of one’s own individualized treatment plan and receive a copy of it.
the right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others
the right to be informed and the right to refuse any unusual or hazardous treatment procedures
the right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit an agency from using closed- circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas
the right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations
The right to have access to one’s own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restrictions
the right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary
the right to be informed of the reason for denial of a service
the right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws
The right to know the cost of services
The right to be verbally informed of all client rights, and to receive a written copy upon request
The right to exercise one’s own rights without reprisal, except that no right extends so far as to supersede health and safety considerations
The right to file a grievance
The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested
The right to be informed of one’s own condition and,
The right to consult with an independent treatment specialist or legal counsel at one’s own expense
Grievance Procedure:
All patients are guaranteed the protection of fundamental human, civil, constitutional and statutory rights. As part of these rights, patients have the right to file a grievance with the organization.
Any current or former patient of KAV Health Group may file a grievance with the client advocate of KAV. The grievance should include: date, time, description of the incident or situation, and the names of the individuals involved. The client advocate will assist the griever in filing a grievance upon request.
The grievance must be put into writing. However, if the grievance is made verbally and the client advocate shall be responsible for preparing the written text of the grievance.
The griever may use the KAV Health Group Complaint/Grievance Form. The form should be signed by the patient or individual filing the grievance on behalf of the patient, and the grievance should be submitted in writing to the client advocate. KAV Health Group Client Advocate:
Regional Client Advocate
5563 Far Hills Ave
Dayton Ohio 45429
Following submission of a grievance, the client advocate will respond to the griever with a written acknowledgment of receipt of the grievance within three business days of receipt of the grievance. This written acknowledgment will include: the date the grievance was received; summary of the grievance; an overview of the grievance investigation process; a timetable for completion of the investigation and notification of resolution; and the treatment provider contact name address and telephone number.
KAV will make a resolution decision on the grievance within 20 business days or receipt unless there are extenuating circumstances indicating a need for extension. In which case, written notification will be given to the griever.
If the grievance cannot be resolved to the grievers satisfaction through the client advocate, he/she may request a hearing with the medical, clinical and operations managers.
At any time, the patient or his/her designated representative has the option to file a grievance with outside organizations such as; the Ohio Department of Mental Health and Addiction Services by phone at 614-466-2596 or in writing at OMHAS, 30 E Broad St suite 742, Columbus Ohio 43215; Disability Rights Ohio by phone at 800-282-9181 or in writing at Disability Rights Ohio, 200 S Civic Dr suite 300, Columbus, Ohio 43215; The U.S Department of Health and Human Services 200 Independence Ave S.W Washington, DC 20201; The Joint Commission by phone at 630-792-5800 or in writing at 1 Renaissance Blvd, Oak Brook Terrace, Illinois 60181; or the appropriate local/state/federal licensing or regulatory associations.
1. How We May Use and Disclose Protected Health Information
We may use and disclose your PHI without your authorization for the following purposes:
Treatment: To provide, coordinate, or manage your healthcare and related services. For example, we may share information with other healthcare providers involved in your treatment or in the case of a medical emergency.
Payment: To obtain payment for services we provide, including billing and collections. This may include disclosing necessary information to your insurance provider.
Healthcare Operations: For quality assessment, staff training, accreditation, and other internal functions that support treatment and payment.
As Required by Law: When required to do so by federal, state, or local law (e.g., reporting abuse or neglect, law enforcement requests).
Public Health and Safety: To prevent or reduce a serious threat to the health or safety of an individual or the public.
Health Oversight Activities: To authorized government agencies conducting audits, investigations, or inspections.
Judicial and Administrative Proceedings: In response to a court or administrative order or legal process.
Other Authorized Uses: For specific uses such as research, organ donation, or worker’s compensation, when allowed by law.
Any use or disclosure of your PHI not covered by this policy will be made only with your written authorization, which you may revoke at any time.
2. Your Rights Regarding Your Protected Health Information
You have the following rights regarding the PHI we maintain about you:
Right to Access: You may request to view or obtain a copy of your medical records and billing information.
Right to Amend: If you believe information we have about you is incorrect or incomplete, you may request an amendment.
Right to an Accounting of Disclosures: You may request a list of disclosures we made of your PHI (excluding those made for treatment, payment, and operations).
Right to Request Restrictions: You may request restrictions on how we use or disclose your PHI. While we are not required to agree, we will comply with your request if legally required to do so.
Right to Request Confidential Communications: You can ask us to communicate with you in a specific way (e.g., at a different address or phone number).
Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
3. Our Legal Duties
KAV Health Group is required by law to:
Maintain the privacy and security of your Protected Health Information;
Provide you with this notice of our legal duties and privacy practices;
Abide by the terms of this Privacy Policy currently in effect;
Notify you in the event of a breach of unsecured PHI that may affect your privacy.
