Notice of Privacy Practices


For Individuals Served and/or Personal Representatives


Click here to download a pdf of our Notice of Privacy Practices

About Our Agency

MOKA, as a contract agency with the local Community Mental Health agencies, has been chosen to assist individuals to obtain various medical and mental health care services. In fulfilling this role we perform a variety of acts. Some of the time we provide health services. At other times, we may coordinate these services for you with another agency such as a hospital, school, Social Security offices, Department of Health and Human Services (DHHS), lawyers, or courts. We also submit information about you to get paid for your services. We will bill you, your insurance company, or any third party who may be paying. In any of these situations, we may need to access information about you or the health care services you receive.

Privacy Notice Introduction

When you contact or come to our agency, a record is usually made. These records may contain Protected Health Information (PHI) is all individually identifiable health information that is created or received by MOKA that relates to your past, present or future physical or mental health condition, the provision of health care services and payment for those services. Examples of identifiable health information includes: your name, address, telephone number, social security number, health insurance information, and date of birth; your diagnosis (the condition for which you are receiving treatment), information including how you say you feel, what health problems you have, treatments you may have been given, observation by health care providers, and your treatment plan and goals. How we use this information is explained in more detail in this notice.

General Privacy Information

We know that your health information is personal. We are careful about how we use your information and work hard to protect your privacy. We do not sell your protected health information and we take steps to protect your information from people who do not have the need and/or the legal right to see it.

We are required by Law to make sure that any PHI that identifies you is kept private, give you this Notice of our legal duties and privacy practices, and follow the terms of the current Notice.

We may make changes to this Notice in the future. If we make a change, it will become our current Notice. We will notify you in the event of a change to this Notice. Copies of the Notice can be obtained from any of our office locations. We will have you sign a statement telling others we gave you this Notice.

Uses for Treatment, Payment, and Operations

Routine disclosures are the ones we need to make as a part of serving you. We do not need any specific consent or permission from you for treatment, payment purposes, or for agency operations, this means:

  • Treatment. We will use and disclose your protected health information (PHI) to provide, coordinate, or manage your supports, care and any other related services. This includes the coordination or management of your health care with another person like a doctor or therapist for treatment purposes.
  • Payment. Your PHI will be used and disclosed to obtain payment for the services provided. This may include talking with your health insurer to get approval for treatment. It may also include statistical reports to agencies making funds available to us for your benefit.
  • Operations. We may use or disclose your PHI for our operations in order to maintain or improve services. This can include quality assessment, accreditation, licensing or business management and general administrative activities.

Other uses and disclosures included within treatment, payment, and operations include:

  • Appointments. To remind you of an appointment.
  • Treatment Options. To tell you about potential treatment options.
  • Benefits and Services. To tell you about health benefits or services that may be of interest to you.
  • Education. Training of health professional students such as supports coordinators and therapists who are working in our agency.
  • Research. For research purposes if the study is approved by our Privacy Officer, Human Rights committee, the Executive director and also meets the requirements of Federal and State law and regulation (e.g., 42 CFR Part 2.).
  • Fundraising & Other Communications. We may use or disclose parts of your PHI to offer you information that may be of interest to you. For example, we may use your name and address to send you newsletters or other information about activities. If we contact you to raise funds, we will inform you of our intention and your right to opt out of receiving such communications.
  • Business Associates and Subcontractors. We may contract with people, companies, and entities known as Business Associates to perform various functions or provide certain services. In order to perform these functions or provide these services, Business Associates may receive, create, maintain, use, and/or disclose your PHI, but only after they sign an agreement with us requiring them to implement appropriate safeguards regarding your PHI. Similarly, a Business Associate may hire a Subcontractor to assist in performing functions or providing services in connection with your services. If a Subcontractor is hired, the Business Associate may not disclose your PHI to the Subcontractor until after the Subcontractor enters into a Subcontractor Agreement with the Business Associate that also requires the Subcontractor to safeguard your PHI.

We may also release your protected health information (PHI) to the local Community Mental Health agency that has authorized your treatment. The local Community Mental Health agency may release your information consistent with Federal and State Laws. If you would like a copy of the Community Mental Health Notice, please ask us.

Uses and Disclosure without Your Authorization

When required by law, we may also disclose some PHI. Such disclosures must also be consistent with law and regulation (e.g., 42 CFR Part 2). For example, we may provide limited information:

  • Health Risk or Death. To prevent, control or report disease, injury, disability or death.
  • Abuse, Neglect or Domestic Violence Reporting. To alert State or local authorities if we believe someone is a victim of abuse or neglect or domestic violence.
  • Health Oversight. To health oversight agencies for things like audits; civil or administrative reviews, proceedings, inspections and licensing activities.
  • Judicial and Administrative Proceedings. In response to an order of a court.
  • Research. For research purposes if the study is approved by our Privacy Officer, Human Rights committee, the Executive director and also meets the requirements of Federal and State law and regulation (e.g., 42 CFR Part 2.).
  • Law Enforcement. To a law enforcement official upon an order of a court or to report a crime on the agency premises.
  • Department of Health and Human Services (HHS). For assurance that we are following the law.

Privacy Rights & Your Rights Regarding Your Protected Health Information (PHI)

  • Right to Request Restrictions. You may request limitations on the use of your PHI. For example, you can ask that your information not be shared with certain family members. We are not always able to comply with these requests. If we are unable to or do not agree to your request, we will let you know. If we do agree to a restriction and the restricted information is needed for your emergency care, we may still use or disclose the information as we think appropriate.
  • Right to Request Alternate Methods of Communication. You may request an alternate method of receiving confidential mails and other communications of your protected health information (PHI). For instance, you may request that your PHI be sent to a post office box rather than to your home address. You may also request that calls be made to a certain telephone number. We do not require that you state a reason for your request.
  • Right to Review and Copy. You may request a copy of your protected health information. You may also request to review your health information. If your request is accepted, we will arrange a mutually agreeable time for you to look at your protected health information. We may deny your request to review and copy in a few limited circumstances. If your request is denied, you may ask for a review of that denial by contacting our Privacy Officer. The contact number for our Privacy Officer can be found under the section that is titled “Privacy Officer and Concerns of Individuals Served.” Copies of protected health information may be provided to consumer for a reasonable fee. We will let you know what the fee (if there is one) will be before a copy of your personal health information is made.
  • Right to Request an Amendment. You may request an amendment to your PHI if you think it is incorrect or incomplete. We may ask that the request be in writing and state the reasons for the amendment. We will notify you to let you know if we agree or disagree with your request. If we do not agree, we will provide you with information on why we disagree and what options you have. To request an amendment, please contact our privacy officer. The phone number to reach the Privacy Officer can be found under the section (below) that is titled “Privacy Officer and Concerns of Individuals Served.”
  • Right to an Accounting of Disclosures. You have the right to request a periodic accounting of the disclosures of your protected health information so that you will be aware of who has had access to your information. Your request may specify a time period which may not be longer than six years. We are not required to provide an accounting for disclosures prior to April 14, 2003. Not every disclosure made is included in the accounting. Disclosures you authorized in writing, routine internal disclosures such as those made to agency personnel in the course of providing you services, and/or disclosures made in connection with payment are all examples of things not included in the accounting. The accounting will state the time of the disclosure, the purpose for which it was disclosed and a description of the PHI disclosed. If there is any fee for the accounting, we will let you know what it is before the accounting is done.
  • Right to Receive a Copy. Copies of this Notice will be available upon request at agency facilities and is also available on the agency website at
  • Uses Requiring Authorization. There are some uses of protected health information that require your authorization. If your PHI is sought for a use that requires your approval, you will be told the reason for the request, who is asking for the information, and what information is requested. There will also be an explanation of how you may cancel (revoke) your authorization. If we have already acted in reliance upon your authorization or consent, you may not be able to cancel it.
  • Breach Notification Requirements. You have a right to be notified upon a breach of your unsecured PHI. We will also inform the Department of Health and Human Services (HHS) and take any other steps required by law.
  • Privacy Officer and Concerns of Individuals Served. You may believe that your protected health information has not been handled in a way that respects your privacy. You may also seek to appeal a denial of your request to review or amend your protected health information. Please feel free to express your concerns to our Privacy Officer. Our Privacy Officer is very helpful and experienced in responding to questions about our programs and services. Making an issue or complaint known is simple to do by calling:

    Privacy Officer 1-800-644-2434

    Services we provide or pay for will not be affected by your raising a privacy issue.

Another way you can express your concern is to contract the Secretary of Health and Human Services at 201 Independence Avenue SW, Washington DC, 20201, or by calling (202) 619-0257 or 1-800-696-6775.