Cirque Lodge Notice of Privacy Practices

This Notice describes how medical information about you may be used or disclosed and how you can access said information. Please review this carefully. Upon written request, residents of Cirque Lodge may access a more robust version of our Privacy Policy within our Policy and Procedure Manual.

This Notice of Privacy Practices is provided to the reader under the Health Insurance Portability and Accountability Act (HIPAA). It applies to all records received and created pertaining to the resident’s physical and mental condition and the treatment of such conditions. It also applies to the billing and payment for those treatments. All this information, hereinafter referred to as PHI, can and will be maintained, used, or disclosed by Cirque Lodge or our affiliated agencies, contractors, or volunteers.

Commitment to Privacy

The protections described herein reflect Cirque Lodge’s commitment to complying with State and Federal privacy laws. Cirque Lodge is required to maintain the privacy and security of your PHI. We are required to provide you with your “resident rights” which include but are not limited to notifying you of any unauthorized disclosure, use, or breach of your PHI, and adhering to the terms of this Notice.

Permitted Uses and Disclosures

Any use or disclosure of your PHI requires your written authorization. Your authorization may be revoked by you at any time. Either by written notification or verbally. Should you discharge from care any authorizations to disclose PHI will terminate one (1) year from the date of the authorization. No information will be disclosed without your express written consent unless required by a medical emergency or in the case of a “duty to warn”.

Treatment – Cirque Lodge can and will provide physicians, therapists, and pharmacists medical information in connection to providing you with care. Also, in the event of your incapacity or an emergency Cirque Lodge reserves the right to disclose medical information based on our professional judgment that is in the best interests of the resident.

Payment – Cirque Lodge will use your PHI for the purpose of obtaining reimbursement for your care with any third-party agency involved in the payment of services. We also reserve the right to disclose your sources of payment to our contractors, or affiliated agencies to enable them to obtain payment for services rendered for a resident’s care that is not covered in our pricing.

Operations – Cirque Lodge reserves the right to use or disclose your PHI for the purposes of our compliance programs, or in our licensing and accreditation efforts. We also reserve the right to use your PHI in our internal quality control programs, an example of which would be the comparison of outcomes of residents who have the same diagnosis but are treated with different medications or modalities.

Permitted Transmission of Information

Cirque Lodge upon request for a resident’s PHI will transmit said PHI by email, fax, or any reasonably requested medium to you or your designee. Cirque Lodge will only transmit that information outside our facility with a valid signature and written consent. Please know however that any transmission outside of Cirque Lodge carries with it a certain level of risk that your information could be read by an unauthorized third party.

Purpose for the Use and Disclosure of your PHI

Cirque Lodge will only disclose your PHI with your expressed consent.

Such disclosures include but are not limited to, information for a family or friend that you identify as a person or persons involved in support of your health care or payment for said health care. Information may be disclosed to your identified agent regarding details such as your location, general condition, or death.

Progress / Psychotherapy Notes – In recognition of the special nature of the therapy session, and of the notes gleaned from said sessions, we are permitted by law to separate those notes from the rest of your medical record. We will not include those notes in any disclosure without your expressed written consent except for our use in situations such as legal action or any proceedings brought against our facility by you. We also can use that information when in our professional judgment we may prevent or lessen a serious or imminent threat to a person or to the public. Progress notes do not include prescriptions, monitoring, different treatment modalities, or the frequencies of said modalities. They do not include clinical tests, functional status, or the Multidisciplinary treatment plan. We are not required by HIPAA to allow you access to your Psychotherapy notes unless our clinical estimation is that doing so will not be harmful to you.

Right to Inspect or Request your PHI

You have the right to inspect or request a copy of your PHI for as long as we maintain it apart from the Progress / Psychotherapy notes as mentioned above. We are required by law to maintain your records for a minimum of seven (7) years from the date of your discharge at which time the record is deleted. We do not disclose actual test questions or raw data of psychological tests that are copyright protected.

Costs – We may charge a reasonable cost to provide you with a copy of your PHI.

Right to Amend – If you believe that the information contained in the PHI is incorrect you may request an amendment to the PHI. Please know that while we accept requests to amend a record we are not required to make such changes. The requests may be denied in situations where we did not create the information or situations where we believe the record is true and accurate.

Revocation of Authorization – You have the right to revoke your authorization to use or disclose your PHI at any time. Such revocation however will not apply to any action Cirque Lodge took in reliance on your authorization prior to the receipt of your revocation.

Breach of Notification – Should Cirque Lodge inappropriately use or disclose your PHI you will be notified immediately of said breach. Notice of any such use or disclosure with be made in accordance with State or Federal law.

Accounting of Disclosures – You have the right at any time to request from Cirque Lodge any disclosures we have made of your PHI. We are not however required to account for (1) disclosures made for treatment or payment. (2) Disclosures made with your authorization. (3) Disclosures made directly to you.

Contact Information

If you would like more information about our privacy practice or if you have any questions, comments, or concerns please feel free to contact:

Gary Fisher
Executive Director
Cirque Lodge
gary@cirquelodge.com
(801) 222-9200



About Cirque Lodge
Cirque Lodge is a recovery retreat providing cognitive and experiential therapies, in the pristine natural beauty of Utah’s Rocky Mountains.

Cirque Lodge is considered among our colleagues, as one of, if not the premium drug and alcohol rehab facility in the country.
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Information
The Lodge
3114 E Ida's Rd, Sundance, UT 84604
The Studio
777 N Palisade Dr, Orem, UT 84097
800.582.0709
info@cirquelodge.com
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