Chicago Patient Handbook 2023 - 33

What are the consequences of
refusing to supply requested
information?
Certain financial information is needed to determine
your ability to pay for the services you receive. If
you cannot afford such services but refuse to supply
information concerning your family income and size,
the result could be discharge from Hazelden Betty Ford.
Clinical information relating to your social history and
present concerns is necessary in order for our staff to
correctly and completely assess your treatment needs
and develop a plan for meeting them. If you do not
supply such information, it cannot be determined which
services are most appropriate for you and will make it
difficult for us to carry out an effective treatment plan
for you and/or your family members.
How can I verify and contest the
accuracy of written information
about myself?
Submit a written request to us describing the nature of
your disagreement to the following address:
Hazelden Betty Ford
Attn: Medical Records
15251 Pleasant Valley Rd, P.O. Box 11
Center City, MN 55012-0011
Patient Health Information/
Records
In the course of providing service to you, Hazelden
Betty Ford collects and uses pertinent health
information and stores it in a secure medical record,
which is the property of Hazelden Betty Ford. Hazelden
Betty Ford complies with applicable state and federal
laws that govern medical record practices. Significant
laws are: 42 CFR Part 2, a federal regulation protecting
the confidentiality of alcohol and drug treatment
records; and HIPAA, a federal standard on privacy
of protected health information called the Health
Insurance Portability and Accountability Act.
Notice of Nondiscrimination and
Accessibility Requirements
Hazelden Betty Ford Foundation complies with
applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin,
age, disability or sex.
Services provided:
Hazelden Betty Ford Foundation provides services and
aids to patients, family members and companions free
of charge to ensure effective communication with the
Foundation. Such services include, but are not limited to
the following:
* Qualified sign language interpreters
* Qualified spoken language interpreters for people
whose primary language is not English
* Written information in other language and formats
(e.g. large print, audio, accessible electronic formats)
* Auxiliary aids
If you are in need of these services, contact us at:
AccessibilityAdvocate@HazeldenBettyFord.org
To file a grievance:
If you believe that Hazelden Betty Ford Foundation
has failed to provide these services or discriminated in
another way on the basis of race, color, national origin,
age, disability, or sex, you can file a grievance with the
Foundation at:
Hazelden Betty Ford Foundation
Attn: Accessibility Advocate
15251 Pleasant Valley Road, Mail Stop RE3
Center City, Minnesota 55012
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office of
Civil rights electronically through the Office of Civil
Rights Portal, available at Office for Civil Rights
Complaint Portal: ocrportal.hhs.gov/ocr/smartscreen/
main.jsf, or by mail or phone at:
U.S. Dept of Health and Human Services
200 Independence Avenue, SW,
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at: hhs.gov/ocr/office/
file/index.html
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Chicago Patient Handbook 2023

Table of Contents for the Digital Edition of Chicago Patient Handbook 2023