West Los Angeles Handbook 2023 - 34

these releases of information or exceptions, please
consult with your counselor.
In the unlikely event that special concerns arise
about your wellbeing and safety, Hazelden Betty Ford
would like your permission to notify a friend, family
member, or other person on your behalf. Your written
authorization is needed for this purpose and would be
used only in the event of a crisis.
A crisis is defined by Hazelden Betty Ford as an event or
condition having a significant negative impact on you
(the patient), your family, or other concerned person(s).
These may include your discharge from Hazelden
Betty Ford against staff advice or at staff request; your
absence from Hazelden Betty Ford without leave;
your discharge or transfer for medical or psychological
reasons; significant injuries or condition, whether life
threatening or not, that Hazelden Betty Ford staff deem
substantial enough to warrant notification of a family
member or other concerned person.
Hazelden Betty Ford asks you to designate at least
one person who may be notified on your behalf in a
crisis. However, your treatment cannot be denied if
you choose not to sign an authorization to disclose
information for this or any other purpose, and you may
revoke it at any time during or after your stay.
Your Privacy Rights
As a patient of this program, you have the right to
privacy and to review information kept in your file. You
have the right to the following:
* Be told why the information we request is needed.
* Be told how the information will be used.
* Be shown information about yourself.
* Be told of the consequences of refusing to supply the
requested information.
* Contest the accuracy of the information in your file.
These rights are more fully explained below.
Why is the information needed?
The information requested about you, your household,
and family members is needed for one or more of the
following reasons:
* To determine whether you are eligible for services.
* To enable us to collect federal, state, or county funds
for services or assistance you receive.
* To help us evaluate your needs for services and
develop a plan to meet those needs.
* To meet federal, state, and local statistical
requirements.
How will the information be used?
Program staff members and employees of Hazelden
Betty Ford will use the information we collect for
clinical, management, planning, and evaluation
purposes. No information will be released to any other
agency or individual without your written consent.
What information do I have access to?
You may request in writing to be shown private
information concerning yourself that is maintained
by us. You are entitled to see such information about
yourself.
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
33
West Los Angeles Handbook 2023

Table of Contents for the Digital Edition of West Los Angeles Handbook 2023
