1743 Sycamore Avenue, Kingman, Arizona 86409
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Mohave Mental Health Clinic (MMHC) and Northern Arizona Regional Behavioral Health Authority (NARBHA) understand that medical information about you and your health is personal.

We are committed to protecting medical information about you. MMHC and NARBHA create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices applies to all of the records of your care generated and/or maintained by MMHC and NARBHA, including the following people and organizations:

  • Any health care professional who is authorized to enter information in your medical record;
  • Any member of a volunteer group that we allow to help you while you are receiving services.

This Notice will tell you about the ways in which we may use and disclose medical information about you.
We also describe your rights and certain obligations we have regarding the use and disclosure of medical

MMHC and NARBHA are required by law to:

  • Make sure that medical information that identifies you is kept private.
  • Make sure that you are given notice of our legal duties and privacy practices with respect to medical information about you.
  • Make certain that MMHC and NARBHA follow the terms of the notice that is currently in effect.

NOTE: In reading this Notice, “you” also refers to “your medical care decision maker.

How we may use or disclose medical information about you

The following information describes different ways we use and disclose medical information. If you arereceiving services for the evaluation or treatment of substance abuse or communicable diseases, including Human Immunodeficiency Virus (HIV) conditions, specific rules apply to the use and disclosure of information related to those services. Please refer to the sections entitled Substance Abuse Health Information and Communicable Disease Related Information for those rules.

For Treatment. We may use medical information about you to provide you with behavioral health treatment or services. We may disclose medical information about you to psychiatrists, your primary care physician, nurses, therapists, case managers and other behavioral health professionals who are involved in your care. For example, a psychiatrist treating you may need to know if you have allergies to certain psychotropic medications. The psychiatrist may need to contact your primary care physician to obtain that information. Different departments or organizations within our clinics may also share information about you in order to coordinate the different services you need, such as
medications, therapy, or case management. If you are in jail, your medical information may be Page 2 of 5 Effective Date: 11/01/04 Last Revised: 07/01/05 shared with necessary medical personnel to coordinate your ongoing care. Your treatment provider may request your signed authorization for some treatment disclosures as a way to inform and involve you with the course of your treatment, although it is not required in all cases.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed and payment may be collected from appropriate payers, such as NARBHA, or an insurance company or a third party. For example, we may need to give NARBHA, or an insurance company, or a third party, medical information about treatment you received at a hospital so that MMHC or NARBHA, or an insurance company or third party can make payment. We may also need to tell your provider agency about any services you are going to receive to obtain prior approval or to determine whether your insurance will cover the services.

For Health Care Operations. We may use and disclose medical information about you for the business activities of MMHC and NARBHA. These uses and disclosures are necessary for administrative functioning and to ensure our members receive quality care. For example, we may use medical information about you to review a provider’s treatment and services and to evaluate the performance of their staff in caring for you. We may combine medical information about many clients to decide what additional services the provider agency or MMHC should offer, what services are needed, and whether new treatments are effective. We may send you a client satisfaction survey to determine how we can improve services. We may use and disclose medical information about you to assess MMHC’s and NARBHA’s compliance with Arizona Department of Health Services, Arizona Health Care Cost Containment System (AHCCCS), or the Joint Commission on Accreditation of Healthcare (JCAHO) standards. For example, this disclosure may be required to evaluate the quality of services we provide or to resolve specific treatment issues you have raised.

Persons Involved in Your Care. We may release limited information about you to a person, including a family member actively involved in your care and treatment or supervision, as allowed under Arizona State law and in accordance with our policies and procedures. For example, we may release the type and dose of medication you are receiving to your spouse if that spouse is actively involved in your care and treatment.

Research. Under certain limited circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve the care and recovery of all clients who receive one medication for the same condition. All research projects are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are.

Information Regarding Deceased Individuals. Your death may increase the accessibility to your records. Besides your health care decision maker, your records may be disclosed to your personal representative or administrator of your estate, if there is not one then your spouse unless you were legally separated, then the trustee of a trust created by you where you were the trust beneficiary, then an adult child, then an adult sibling, then a guardian at the time of death. See A.R.S. § 12-2294(D).

SUBSTANCE ABUSE HEALTH INFORMATION. The confidentiality/privacy of alcohol and drug abuse client records related to the diagnosis, treatment, referral for treatment or prevention, is protected by federal law and regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3) and regulation (42 C.F.R. part 2). Generally, a substance abuse program may not disclose to anyone outside the program that a client attends the program or disclose any information identifying a client as an alcohol or drug abuser, unless:

  • The client authorizes in writing. A general authorization for the release of medical or other information is not sufficient for this purpose.
  • The disclosure is allowed by a court order.
  • The disclosure is made to medical personnel in a medical emergency.
  • The disclosure is made to qualified personnel for research or to oversight agencies, funders and other authorized auditors for audit or program evaluation. Page 3 of 5 Effective Date: 11/01/04 Last Revised: 07/01/05
  • The client commits or threatens to commit a crime either at the program or against any person who works for the program.
  • The disclosure is made to report suspected child abuse or neglect.

COMMUNICABLE DISEASE RELATED INFORMATION. Communicable disease related information, including HIV-related information, is kept strictly confidential and released only in conformance with the requirements of state law (A.R.S. §§ 36-664 and 36-665). A general authorization for the release of medical or other communicable disease related information is not sufficient to release HIV-related information. A written authorization must specifically indicate that it is for the release of confidential HIVrelated information.

Special Circumstances

For medical information, other than substance abuse health information and communicable disease related information, which are discussed above, the following special circumstances apply. Federal and state laws allow or require MMHC and NARBHA to disclose medical information other than substance abuse, communicable disease or HIV information about you without your written authorization in certain special situations, if they occur.

Public Health Risks (Health and Safety for you and/or others). We may disclose medical information about you for public health activities, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. These activities generally include the following:

  • To prevent or control disease, injury or disability.
  • To report births or deaths.
  • To report child abuse or neglect.
  • To report reactions to medications.
  • To notify people of recalls of medications they may be using.
  • To notify a person who may have been exposed to a disease or may be at risk for contracting a disease or condition.
  • To avert a serious threat to the health or safety of a person or the public.
  • To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence. We will make this disclosure when required or authorized by law.

Health Oversight Activities. We may disclose medical information about you to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, accreditation and licensure. These activities are necessary for the government or other agencies to monitor the behavioral health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or legal action, we may disclose medical information about you in response to a court or administrative tribunal order, or pursuant to a subpoena if done in accordance with Arizona law.

Law Enforcement. We may release medical information about you if asked to do so by a law enforcement official:

  • In response to a court order, warrant, summons, or similar lawful process in accordance with Arizona law, and NARBHA and provider policies and procedures.
  • About crimes committed on the premises of the agencies covered by this Notice.
  • About crimes committed against staff of the agencies covered by this Notice.
  • To avert a serious threat to the health or safety of a person or the public (Duty to Warn).

Coroners, Medical Examiners and Funeral Directors. We may release information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release medical information about clients to funeral directors as necessary to carry out their duties.

As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law, and/or as required for national security or protective services.

Your Rights Regarding Medical Information About You

Right to Access. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes progress notes, evaluations/assessments, treatment plans, and billing information, but is not limited to only that information.

To inspect and obtain a copy of your medical information, contact the MMHC Privacy Officer. If you request a copy of the information, you may receive one copy at no cost each year. For any additional copies during the same year, you may be charged a fee for the costs of copying, mailing, or other supplies associated with your request.

Your request to inspect and copy your information may be denied in certain very limited circumstances. If you are denied access to any part of your medical information, you may request that the denial be reviewed. Information regarding how to initiate that review process will be provided in writing at the time of any denial of your access to the information.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as your medical information is kept by MMHC and NARBHA.

To request an amendment, your request must be made in writing and submitted to the MMHC Privacy Officer. You must provide a reason that supports your request. We may deny your request if you ask us to amend information on that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for MMHC or NARBHA;
  • Is not part of the information which you would be permitted to inspect or copy; or
  • Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about you to others. The accounting does not include information disclosed based on your written permission or as a part of treatment, payment, or health care operations. To request this accounting, you must submit your request in writing to the MMHC Privacy Officer. Your request must state a period of time for the accounting that may not be longer than six years and may not include dates before March 1, 2003.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you. We are not required to agree to your request, particularly if it is not in accordance with Arizona or Federal law. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the MMHC Privacy Officer. In your request, you must tell us what information you want to restrict, and to whom you want the restriction to apply.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location if you believe that you will be otherwise endangered. For example, you can ask that we only contact you at a certain Page 5 of 5 Effective Date: 11/01/04 Last Revised: 07/01/05 telephone number or address. To request confidential communications, you must make your request in writing to the MMHC Privacy Officer. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Paper Copy of the Notice. You have the right to a paper copy of this Privacy Notice. You may ask us to give you a copy of the Privacy Notice at any time by requesting a copy from the MMHC Privacy Officer or the NARBHA Privacy Officer, or the MMHC receptionist.

Changes to this notice

MMHC and NARBHA reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we will receive in the future. NARBHA will post a copy of the current notice at its main office and on its website. MMHC will post the notice at all of their service sites and distribute copies to all open members. The notice will contain the effective date at the bottom of each page. MMHC and NARBHA will make you aware of any revisions by posting a revised notice in all the above locations.


If you believe your privacy rights have been violated, you may contact or file a complaint with the Privacy Officer at MMHC, 3505 Western Avenue, Kingman, AZ 86401, or the Privacy Officer at Northern Arizona Regional Behavioral Health Authority, 1300 S. Yale St., Flagstaff, Arizona 86001. For further questions, you may contact the MMHC Privacy Officer at 928-757-8111 (ext. 2255), or the NARBHA Privacy Officer at 1-877-756-4090. If we cannot resolve your concern, you also have the right to file a written complaint with the United States Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

Other uses

Other uses and disclosures of medical information not covered by this notice or the laws that apply to MMHC and NARBHA will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for thereasons covered in your written authorization. MMHC and NARBHA are unable to take back any disclosures already made with your authorization, and are required to retain our records of the care and services we provided to you.