During the process of providing services to you, NorthStar Transitions (“NorthStar”) will obtain, record, and use information about you that is protected health information.  ‘‘Protected health information’’ means any information that we have which identifies you and relates to your health payment for health care services, and alcohol or drug, including mental health, treatment that we provide to you.  NorthStar is committed to protecting the privacy and confidentiality of your personal health information (PHI). We are also mandated by federal and state law to assure that this protection occurs. The following notice outlines our privacy practices, legal duties and your rights concerning your PHI. We are required by law to provide you with a copy of this notice.

NorthStar keeps Medical Records for individuals that have received inpatient services for a period of 10 years and for those that received outpatient services for a period of seven years following the actual discharge from services. Medical Records consist of  your PHI and may include but are not limited to: name, demographic information, referral information, admission notes, admission paperwork, assessments, evaluations, progress notes, treatment plan, medical and medication protocols, continuing care plan, discharge summary and financial/payment information. These records are necessary to provide you with the best interdisciplinary care, continuing care and to receive payment for treatment services from third party payers and are required by state licensing mandates.

Amendments to this notice may be made in writing by NorthStar as laws and or policies change.



Your personal health information (PHI) may be disclosed to any NorthStar staff members as needed to provide you with the best possible care, the most comprehensive treatment and to assure your physical health and safety.

Your PHI will only be disclosed to those outside of NorthStar when your express written consent or authorization has been obtained except as required by law.

Required By Law

NorthStar staff will disclose protected health information about you when required by law or allowable by court order. This includes, but is not limited to:

  • Reporting suspected child abuse or neglect;
  • When court ordered to release information;
  • When there is a legal duty to warn or take action regarding imminent danger to  others;
  • If you are a danger to yourself or others or you are gravely disabled; or
  • If you should die and a coroner is investigating your death.

Crimes on program premises or threats against staff

NorthStar staff will report to the appropriate law enforcement agency a crime committed by a person receiving services at NorthStar on NorthStar property or against any person who works for NorthStar or about any threat to commit such a crime.  This report will include only information necessary to identify and locate the suspected perpetrator or that is directly relevant to the reported activity.


There may be instances when payment for treatment services will require disclosure of your PHI. This is most common when payment is made by a third party such as an insurance company, workman’s compensation, another family member or your personal financial officer. Your PHI will only be disclosed with your express written consent or authorization. It is important to know, however, that your refusal to give such permission may lead to non-payment by that third party as without your written consent or authorization, we will be unable to discuss payment for your treatment services with any third party.

Healthcare Operations

NorthStar may use and/or disclose your PHI for healthcare operations such as: staff training and evaluation, auditing, medical reviews, compliance programs, business planning, licensing, quality assurance, accreditation, certification and credentialing activities.

Teaching / Training / Supervision

We may disclose personal information in the context of teaching, trainings and the supervision of other members in the substance abuse field. Information will be disclosed ONLY when the anonymity of the person can be guaranteed.

Business Associates and Ancillary Service Personnel

Some services may be provided to NorthStar through business associates and ancillary personnel such as auditors, lab technicians, medical providers, pharmacists, transcriptionists, psychiatrists and state licensing representatives. Your PHI may be disclosed to staff at those agencies as needed to assure that such providers can perform the job we have asked them to do. NorthStar has a policy to disclose only that information necessary to assure that job is completed. We further require such business associates to sign a contract that states that they will appropriately safeguard your PHI in compliance with NorthStar policies and legal mandates.

Your Authorization

Although your medical record is the physical property of NorthStar, you have the right to review and receive a copy of your medical record. NorthStar policy requires that any person who wishes to review their medical record do so in the presence of the therapist whom they have or had been working with or another assigned staff member. You may consent for NorthStar to release specific information about you in order to facilitate your treatment.   A written consent or authorization signed by you regarding such medical records must be obtained prior to the copying and or delivery of those records to you.

You may also request that your PHI be disclosed to any person or agency that you choose for any purpose. You must provide a written consent or authorization for that information to be disclosed even when such a request is made by you. Such consent is valid for one year from the date originally signed unless otherwise specified by you. You have the right to revoke your consent or authorization at any time.

Disclosure to Family and Friends

Only the PHI that you have specified will be disclosed and only to those for which you have provided written consent or authorization. NorthStar will not confirm or deny your presence at NorthStar to any individual that you have not signed a consent or authorization for except in the case of an emergency or as required by law. In the event of your incapacity or under emergency circumstances, we will disclose your PHI to the person you had previously designated as your “Emergency Contact Person(s)”.

Appointments, Reminders and Alumni contact

We may use and disclose your PHI to contact you (i.e.: telephone calls, voicemails, e-mails, letters) as a reminder of an appointment at NorthStar, to check on you and your mental health status and regarding alumni events and associations. You have the right to request not to be contacted for such purposes.


To request that NorthStar place additional restrictions on certain uses and disclosures of your information

We are not required by law to agree with your request however, whenever possible as to not cause undue hardship to the flow of business of NorthStar, we will honor such requests.

For instance, you may request that your medical record not be made available to a state-licensing representative from the Office of Behavioral Health during their standard audit of NorthStar. These audits do require that the Office of Behavioral Health have access to any record for those that have received services at NorthStar and that we do not impede in any way random audits of our medical record keeping. Under these circumstances, your request could not be honored. NorthStar does require that such Business Associates sign a written consent to adhere to NorthStar standards regarding your privacy and confidentiality so that none of your PHI will be disclosed.

To obtain a copy of this notice upon request

All those receiving services at NorthStar are given a copy of this notice upon admission and asked to sign an acknowledgement that they have seen it. Anyone receiving services can request an additional copy at any time.

To request a copy of your medical record

You may request a copy of your medical record. NorthStar may deny such request if it or its representatives believe that such access would cause harm to other patients, Northstar personnel or property or yourself. You also do not have the right to access your medical record from NorthStar in the following instances:

  • When information was compiled in reasonable anticipation of or for use in civil, criminal or administrative actions or proceedings.
  • When information was obtained from someone other than a healthcare provider under a promise of confidentiality and the access required would be reasonably likely to reveal the source of the information.
  • When the records were created by a treatment facility or mental health professional that is not a NorthStar employee or Business Associate. It is NorthStar’s policy not to make copies of medical records created by any non-NorthStar employee or Business Associate. In this situation, you must request such records directly from that person or facility that created those records originally.

There are other situations in which NorthStar may deny you access to your medical record. If so, NorthStar is required to provide you with a review of the decision denying such access. Reviewable grounds for denial include but are not limited to:

  • When a licensed staff member of NorthStar has determined, in their professional judgment that access is likely to endanger the life or physical safety of the person receiving services or another person.
  • When the medical record makes reference to another person receiving services at NorthStar or person other than a provider, and a licensed staff member of NorthStar has determined that such access is likely to cause substantial harm to the person or another person.
  • When the request is made by the person’s personal representative and a licensed staff member of NorthStar has determined that such access is likely to cause substantial harm to the person or another person.
  • When the proper written consents/authorization have not been obtained.

For these circumstances another licensed professional must review the decision and provide a written response within 60 days. This second opinion will be upheld.

To request an amendment or correction to your medical record

If NorthStar staff denies your request for amendment/ correction, we will notify you of why and how you can attach a statement of disagreement to your record (which we may argue) and how you can register a written complaint to our Privacy Officer or the Office of Behavioral Health or Department of Health and Human Services.

If we grant the request, we will make the correction and distribute it to those you identify in writing that you want notified. We do not have to grant the request if NorthStar staff did not create the record. In this case you must seek the amendment/correction from the party who originally created the record. For instance: NorthStar staff has obtained your written PHI from another treatment facility or professional, and there is information contained in those records that you disagree with, NorthStar staff may not legally amend those records in any way.

To request alternative communication

You have the right to request that we communicate with you by alternative means or at alternative locations. Requests need to be made in writing, and must specify the alternative means and location.  You may ask that we call you at home, on your cell phone or at home.  You may ask that we send mail to a different address.

NorthStar responsibilities under federal law

In addition to providing you your rights as detailed above, NorthStar is required to:

  • Maintain the privacy of your PHI: NorthStar will do this by the implementation of reasonable and appropriate physical, administrative and technical safeguards.
  • Provide you with this notice: As to our legal duties and privacy practices with respect to the personal and private information we obtain about you during the course of your treatment at NorthStar.
  • Abide by the terms of this notice
  • Train NorthStar employees, staff and personnel on our privacy and confidentiality policies.
  • Implement a disciplinary plan: NorthStar has a course of disciplinary action for the NorthStar Employees, Business Associates and Ancillary Service Providers who breach our privacy/confidentiality policies. And if such a breach occurs, to lessen any resulting harm this breach may have caused.

NorthStar will not use or disclose your personal and mental health information without your written consent or authorization.

Maintain an account of any non-routine disclosures and uses of your medical records within 60 days of such disclosures. Information provided will include name and address of who received your PHI, a description of the information disclosed, and a statement of the purpose of such disclosure. NorthStar reserves the right to charge a reasonable fee for this service.

NorthStar does not need to obtain your consent or authorization for

  • Disclosures to you.
  • Disclosures consented to or authorized by you.
  • Partially de-identified data used for research, education, public health or health care operations.
  • For the facility directory or to persons involved in your care such as outpatient therapists, psychiatrists or medical doctors.
  • For national security or intelligence purposes, to correctional institutions or law enforcement officials under 164.512(K) (2) and (5).
  • Disclosures that occurred before April 14, 2003.
  • Allow you to revoke your consent to use or disclose your PHI at any time except to the extent that we have previously taken action.

Contact Information

If you have questions, would like further information or believe your privacy rights have been violated you may contact NorthStar’s Privacy Officer.

Grievances should be made in writing and be addressed to NorthStar Privacy Officer, Dale Maugans.

You also have the right to file a grievance with:

Colorado Department of Human Services, Office of Behavioral Health
3824 Princeton Circle, Denver, CO 80236 (303) 866-7400


The U.S. Department of Health and Human Services
Region IV Office for Civil Rights
1301 Young St.Suite 1169
Dallas, TX 75202214-767-4056

NorthStar staff will not retaliate in any way if you choose to file a grievance with NorthStar or The USDHHS.

Call 866-407-2240
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