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Privacy and Security of Client Information

Privacy and Security of Client Information

The privacy and security of your Protected Health Information (PHI) is important to us. The following materials explains how your PHI is protected, accessed, and may be disclosed – including your rights to limit how it is used.

If you have any questions or difficulty in accessing this information, or you would prefer to receive it in an alternative language, please call us at 800-790-8049.


According to the Health Insurance Portability and Accountability Act (HIPAA), your provider or health insurer must give you a notice that tells you how they may use and share your health information and how you can exercise your rights.  In most cases, you will get this notice on your first visit to your provider.

If you need this information in another language, please call 800-790-8049.

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  • i. Attach A appd01 Designated Record Set

    ii. Attach A appd02 Limited Data Set from 45 CFR Part 164.514(e) HIPAA

    iii. Attach A appd03 KCBHO Authorization for Use & Disclosure of PHI

    iv. Attach A appd03A Multi-party Authorization for Disclosure & Use of PHI

    v. Attach A appd03B KCBHO SUD Releases Description

    vi. Attach A appd03C KCBHO Authorization for Use & Disclosure SUD PHI

    vii. Attach A appd03D KCBHO Consent for SUD Client Lookup

    viii. Attach A appd03E KCBHO Authorization to Disclose & Redisclose SUD PHI

    ix. Attach A appd04 Maximum Potential Access to and Use of PHI by KCBHO Staff

    x. Attach A appd05 Routine Disclosure of PHI by BHRD Staff

    xi. Attach A appd06 Redisclosure of Enrollment Information without Client Consent

    xii. Attach A appd06A KCBHO Provider Network MCOs

    xiii. Attach A appd07 Request for Client Information without Authorization

    xiv. Attach A appd08 Form for Invalid Authorizations

    xv. Attach A appd09 Request to Communicate by Alternate Means

    xvi. Attach A appd10 Log of Disclosures without Client Consent or Authorization

    xvii. Attach A appd11 Request to Revoke Consents for the Release of Information

    xviii. Attach A appd12 Request to Amend or Correct PHI

    xix. Attach A appd13 Request to Restrict Access of PHI

    xx. Attach A appd14 Request for an Accounting of Disclosures

    xxi. Attach A appd15 Oath of Confidentiality

    xxii. Attach A appd16 Disclosure of Minimum Necessary Electronic PHI

    xxiii. Attach A appd17A Application for Access to Client Information Systems

    xxiv.  Attach A appd17B Application for Access to Client Information Systems_BHO

    xxv. Attach A appd18 Procedure for Making a CD Containing PHI

    xxvi. Attach A appd19 DSHS Intranet Oath of Confidentiality for PHI

    xxvii. Attach A appd20 KC Business Associate Agreement

    xxviii. Attach A appd21 R&E Data Sharing Agreement

    xxix. Attach A appd21A Data Security Requirements

    xxx. Attach A appd21B Certification of Data Disposition

    xxxi. Attach A appd21C Oath of Confidentiality-R&E Data Sharing Agreement

    xxxii. Attach A appd22 Data Use Agreement for Limited Data Set

    xxxiii. Attach A appd23 DSHS PRISM System Access Request Form

    xxxiv. Attach B  Evaluation and Research Committee

    Contact Us

    Phone 206-263-9000

    TTY Relay: 711

    Fax: 206-296-0583