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Medical Records

We take the privacy of your personal records very seriously at MHA. However, we also know there are times that you may need a copy of records either sent to someone else or for yourself and we want to do our best to help facilitate that. Due to the number of requests we receive, we do ask for up to 30 days to process your request. 

Release of Information Forms

Use this form to have us send information to another agency, school, or professional. Please note, we may also request a release with a physical signature. 

Use this form to request records for yourself, your child, or someone in your care. This form must be printed, completed and sent back to MHA either via fax, email, or postal mail. Please note if the person you are requesting records for is not you or your minor child, we will need a copy of al documents giving you a right to the information. 

Notice of Privacy Practices

This Notice Describes How Medical Information About You For Services Delivered At The Mental Health Association May Be Used And Disclosed And How You Can Get Access To This Information. Please Review It Carefully.


We are committed to protecting the confidentiality of your medical information. We create a record of the care and treatment you receive from Mental Health America of South Central Kansas (MHA). Such information may include work on treatment plan goals, symptoms, changes in your life, and information from other community service providers who are involved in your care and with whom you have signed a release. It also includes billing for services. We need this record to provide you with care and to meet certain legal requirements. This notice applies to all of the records held by MHA personnel. Depending upon the circumstances, Kansas law may further limit the disclosures MHA may make.

This notice will tell you about the ways in which we may use and disclose your medical information. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information. If you cannot read or comprehend this notice as written, let us know and we will read the notice to you. You may request a paper copy of this notice.

MHA is required by law to:

• Make sure that your medical information is kept private except as allowed by law;

• Give you this notice of our legal duties and privacy practices with respect to your medical information, and make a good faith effort to obtain your acknowledgement of receipt of this notice;

• If you are under the age of 18, this notice will be given to your parent or legal guardian who is responsible for consenting treatment;

• Follow the terms of the notice that is currently in effect. MHA does reserve the right to change this notice and its privacy policies as it feels necessary. A revised notice will be available upon request and will be available electronically or at the next treatment opportunity.


MHA will not use or disclose your health information for any purpose not described in this Notice without your written authorization. MHA may use and disclose your health information without your written authorization for the following:

1. Treatment: We will use and disclose your health information in the course of providing, coordinating and/or managing your care and related services provided at MHA by your service providers and to other treaters. For example: Information obtained by an attendant care worker may be shared with your case manager; your therapist may share information with your psychiatrist or case manager.

2. Payment: We will use your health information in order to bill and collect payment from you, an insurance company or other third-party payers for services you receive at MHA. For example: Your health plan may be contacted to get prior approval for coverage of treatment you are going to receive or to determine whether your plan will pay for the treatment and services you receive.

3. Healthcare Operations: We will use your health information to assess the care and outcomes in your case and others like it to operate our business. Our health care operations include, among other things, the following functions: quality assessment and improvement activities; reviewing the qualifications and competence of providers; accreditation, and utilization review. For example: Your information could be used to evaluate the quality of care that you were provided, or your information may be combined with health information of other patients to evaluate the need for new services or treatment.

4. Client Survey: You will receive satisfaction surveys during service to help us evaluate our service and post-discharge to see how you are doing.

5. Appointment Reminders: You may receive appointment reminders in the mail or by phone. Appointment reminders may be left on voice mail at the phone number you have provided to us.

6. Fundraising: You may also receive information about MHA fundraising opportunities and may elect to opt out of these communications.

7. Research: Your PHI may be used by researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and consent form and established protocols to ensure the privacy of your health information.

8. Coroners, Medical Examiners, and Funeral Directors: MHA may use/disclose PHI to the coroner, medical examiner, or funeral director as necessary for them to carry out their duties.

9. Organ and Tissue Donation: MHA may use/disclose PHI to organ procurement organizations or other entities engaged in procurement, banking or transplantation of organs/tissues for the purpose of transplant or donation.

10. Law Enforcement: PHI may be disclosed to a law enforcement official in response to a valid court order, subpoena or warrant, or in response to a official request for the purpose of identifying or locating a missing person, suspect or fugitive; about the victim of a crime; about a death we believe may be the result of criminal conduct; about criminal conduct at our offices; or in an emergency to report a crime, the location of a crime, victims of the crime or to identify the person who committed the crime.

11. Legal Proceedings: We may disclose/use your PHI in proceedings in response to an order, subpoena, discovery request or other lawful process.

12. Public Health Risks: Your PHI may be shared with the appropriate government agency relative to adverse events with respect to food, medications, products and product defects to facilitate product recalls, repairs or replacement, or for post marketing surveillance.

13. Treatment Coordination: We may discuss your treatment with family members or friends who are involved in your care. We may disclose PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition, status, and location.

14. Health Oversight Activities: to an agency for activities authorized by law, such as to prevent or control disease, injury or disability.

15. To Avert a Serious Threat to Health or Safety: We may use/disclose you PHI when necessary to prevent a serious threat to your health or safety or the health and safety of another person.

16. As Required by Law: We will disclose your PHI when required by federal, state or local law. This may include reporting of communicable disease, wounds, abuse, disease registries, health oversight and other public requirements.

17. Military and Veterans: MHA may use/disclose PHI to military command authorities as required by the Department of Veterans' Affairs authorities if you are a member of the military or a veteran.

18. National Security and Intelligence Activities: to authorize federal officials for conducting of intelligence or national security activities, including protective services to the President or other persons as authorized by law.

19. Workers Compensation: We may disclose health information about you for issues involving worker’s compensation or similar programs.

20. Health Related Benefits and Services: We may use your personal information to provide information to you regarding treatment alternatives or health related benefits which may be of interest to you.

21. Inmates/Persons in Custody: MHA may disclose PHI if you are in custody or presently incarcerated to a correctional facility or law enforcement official when the disclosure is necessary for treatment or safety of others.


Uses and disclosures of your health information that are not covered by this Notice or laws that apply to mental health treatment will be made only with your written authorization. If you provide us with written authorization to use or disclose your health information you may revoke that authorization in writing at any time. If you revoke your authorization, such information will not be used or disclosed after the date we receive the revocation. However, a revocation of an authorization does not apply to uses and disclosures prior to the date of the revocation.


You have the right to:

1. Request a restriction on certain uses and disclosures of your health information. Although you have a right to make such a request, please note that we are not required to agree to a requested restriction. If we agree to the restriction, you will be notified in writing. We may however terminate any restriction with or without your agreement. You will be notified that we are terminating our agreement to the restriction. Restrictions must be requested in writing and include what information you want to limit, whether you want to limit use or disclosure or both, to whom you want the restriction to apply.

2. Request an electronic copy of your PHI.

3. Inspect and obtain a copy of your PHI except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or clinical laboratory information access to which is prohibited by law. You may be charged a reasonable fee for obtaining a copy of your records. You may also request that your PHI be sent in an electronic format to another individual.

4. Request amendment of your PHI, if you feel that your record is incorrect or incomplete. You have this right for as long as the information is maintained by MHA. Your request must be in writing with the reason(s) supporting your request and must be given to MHA’s Privacy Officer. Your request to amend your medical record may be denied if: it is not in writing; it does not include a reason to support the request; the information was not created by a provider while you received services from MHA; the information is not part of the medical record; the information is not part of the record which you would be permitted to inspect or copy; the information is accurate and complete. If your request for amendment is denied, you have the right to file a statement of disagreement that will be included with future disclosures of your PHI.

5. Obtain an accounting of disclosures of your PHI. An accounting will not include disclosures for treatment, payment and health care operations described in this Notice or disclosures made pursuant to your written authorization. To request a list of disclosures, you must submit your request in writing with the timeframe (which may not be longer than 3 years) and requested format of the list (print or electronic).

6. Request confidential communications and that we contact you about medical matters in a certain way or at a certain location.

7. Revoke your authorization to use or disclose health information except as to the extent that action has already been taken.

8. Request a paper copy of this Notice.

9. Be notified following a breach of your PHI.


MHA may participate in an electronic health information exchange, or HIE. New technology allows a provider or a health plan to make a single request through a health information organization, or HIO, to obtain electronic records for a specific patient from other HIE participants for purposes of treatment, payment, or health care operations. HIOs are required to use appropriate safeguards to prevent unauthorized uses and disclosures.

You have two options with respect to HIE. First, you may permit authorized individuals to access your electronic health information through an HIO. If you choose this option, you do not have to do anything.

Second, you may restrict access to all of your information through an HIO (except access by properly authorized individuals as needed to report specific information as required by law). If you want to restrict access to your records through the exchange, you must submit a request for restriction through the Kansas Health Information Exchange, Inc. Contact the KHIE Support Center at 785-783-8984 or visit for more information. You cannot restrict access to certain information only; your choice is to permit or restrict access to all of your information. Please be aware that the inability to access restricted information may result in a health care provider not having access to information necessary to provide appropriate care.

Even if you restrict access through an HIO, providers and health plans may share your information directly through other means (e.g., facsimile or secure e-mail) without your specific written authorization. Your information will also be available through the exchange by a properly authorized individual as necessary to report specific information to a government agency as required by law (for example, reporting of certain communicable diseases or suspected incidents of abuse).

For your protection, each request for restrictions is subject to verification procedures. Please allow sufficient time for your request to be processed. Your failure to provide all information required for verification may result in additional delay or denial of your request. If you receive health care services in a state other than Kansas, different rules may apply regarding restrictions on access to your electronic health information. Please communicate directly with your out- of-state health care provider regarding those rules.

If you have questions regarding HIE or HIOs, please visit for additional information.


We require our employees and business associates to follow the Company’s security policies and procedures that limit access to health information about consumers to those employees and or entities that need it to perform their job responsibilities. In addition, the Association maintains physical, administrative and technical security measures to safeguard your protected health information.


If you believe that your privacy rights have been violated you may file a complaint with the Secretary of Health and Human Services. You may also direct any complaints to MHA’s Privacy Officer at 555. N. Woodlawn, Suite 3105, Wichita, KS 67208. 316.685.1821. You will not be retaliated against for filing a complaint.


If you have questions about your privacy rights as described in this Notice and/or about our responsibilities as to your health information, please contact MHA‘s Privacy Officer at the following address and/or phone number: Privacy Officer, 555 N. Woodlawn, Suite 3105,Wichita, Kansas 67208. Phone: (316) 685-1821

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