Effective April 14, 2003
Revised February 1, 2005
Revised March 15, 2006
Revised September 7, 2006
THE ARC OF THE FARMINGTON VALLEY, INC.
Important
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION.
PLEASE REVIEW IT
CAREFULLY.
[45CFR164.520(b)]
before
signing the Consent and Acknowledgment Form.
If
you have any questions about this Notice or would like further information concerning your privacy rights, please contact
FAVARH’s Privacy Officer at:
The Arc of the Farmington Valley, Inc.
860-693-6662
x 113
The Arc of the Farmington Valley, Inc.
Purpose of
the Notice of Privacy Practices
This Notice of Privacy
Practices (the “Notice”) is meant to inform you of the uses and disclosures of
protected health information that we may make.
It also describes your rights to access and control your protected
health information and certain obligations we have regarding the use and
disclosure of your protected health information.
Your “protected health information” (PHI) is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.
We are required by law to maintain the privacy of your
protected health information. We are
also required by law to provide you with this Notice of our legal duties and
privacy practices with respect to your protected health information and to
abide by the terms of the Notice that is currently in effect. However, we may change our notice at any
time. The new revised Notice will apply
to all of your protected health information maintained by us. You will not automatically receive a revised
Notice. If you would like to receive a
copy of any revised Notice you should access our web site at www.favarh.org or contact The Arc of the
Farmington Valley, Inc. (“FAVARH”) directly.
The Arc of the
Farmington Valley, Inc. personnel understand that information about your health
and program is personal. We are
committed to protecting health information about you. We create a record of care and description of
the services you receive from The Arc of the Farmington Valley, Inc. We need this record to provide you with
quality services and to comply with certain programmatic and legal
requirements. This notice applies to all
of the information about your services provided at
Other providers of service may have different policies or notices regarding the information they maintain about your health.
FAVARH will ask you to sign a consent form that allows FAVARH to use
and disclose your protected health information for treatment, payment and
health care operations. You will also be
asked to acknowledge receipt of this Notice.
The following categories describe some of the different ways
that we may use or disclose your protected health information. Even if not specifically listed below, FAVARH
may use and disclose your protected health information as permitted or required
by law or as authorized by you. We will
make reasonable efforts to limit access to your protected health information to
those persons or classes of persons, as appropriate, in our workforce who need
access to carry out their duties. In
addition, if required, we will make reasonable efforts to limit the protected
health information to the minimum amount necessary to accomplish the intended
purpose of any use or disclosure and to the extent such use or disclosure is
limited by law. [45CFR164.506(a)]
We May Use and
Disclose Your Protected Health Information For:
1. Treatment:
The Arc of the Farmington Valley, Inc. staff and/or volunteers may use and disclose your protected health information to provide you with medical treatment and related services. If we are permitted to do so, we may also disclose your protected health information to individuals or facilities that will be involved with your care after you leave FAVARH and for other treatment reasons. We may also use or disclose your protected health information in an emergency situation. We may disclose your protected health information including your photo to The Arc of the Farmington Valley, Inc. Clinical Services, Community Services, Day Services, Residential Services, or other departments as required.
For example:
§The
staff and/or volunteers may need to know that you are taking a certain
medication or have a condition such as seizures that may effect your program.
§We
may disclose your protected health information to doctors, nurses, State of
Connecticut Departments providing you services (i.e., Education, Public Health,
Mental Health, Mental Retardation Services, Labor, ICF Inspectors, Motor
Vehicles, Workman’s Compensation), Federal Departments (i.e. Social Security
Administration, Department of Labor, etc.), Town Boards of Education and School
Personnel, Town Parks & Recreation Programs, Property Insurance Companies
for accident claims, potential or current Employers, Special Olympic Volunteers
or Personnel, or other health providers who are involved in taking care of
you. For instance, a doctor taking care
of you for an injury may need to know if you have diabetes because diabetes may
effect treatment.
§PHI shared with Town Boards of Education
is exempt from HIPAA regulations.
Nevertheless, FAVARH staff will seek to maintain client confidentiality
and security for student records maintained by FAVARH staff.
§PHI
shared with the Special Olympics organization, organizers or partners is exempt
from HIPAA regulations. Nevertheless,
FAVARH staff will seek to maintain client confidentiality and security for
olympian’s records maintained by FAVARH staff.
§As
part of your treatment and program for community integration, we may use your
photo and name in public relations
events. If we do so, we will do
so only with a release signed by you or your personal representative.
§We
may disclose your protected health information to people such as family members
or others who take part in your support outside of The Arc of the Farmington
Valley, Inc. [45CFR164.506( c)]
2. Payment:
We may use and disclose your protected health information so that we can bill and receive payment for the treatment and related services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid, Department of Mental Retardation, Department of Social Services, Social Security Administration, or another third party payor. For example, we may need to give your health plan information about the treatment you received so your health plan will pay us or reimburse us for the treatment, or we may contact your health plan to confirm your coverage or to request prior authorization for a proposed treatment.
For example:
§The Arc of the Farmington Valley, Inc., bills and provides information to the State of Connecticut Departments of Social Services and Mental Retardation; the Federal Department of Social Security; Other Public Departments/Towns; and/or other Private Payors/Grantors for Administrative, Day, Residential, Community or Clinical Services provided to The Arc of the Farmington Valley, Inc. participants and their families.
3. Health Care Operations:
We may use and disclose your health information as necessary for operations of FAVARH, such as quality assurance and improvement activities, reviewing the competence and qualifications of health care professionals, medical review, legal services and auditing functions, and general administrative activities of FAVARH.
For example:
§ We may use your protected health information to review our programs and services and to evaluate the performance of our staff and/or volunteers or the performance of a contracted provider.
§ We may combine health information about many individuals to decide what changes in service might be needed.
§ We may also use combined information to evaluate how we are managing changes in resources or services.
4. Business Associates:
There may be some services provided by our business associates, such as a billing service, transcription company or legal or accounting consultants. We may disclose your protected health information to our business associate so that they can perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.
5. Appointment
Reminders:
We may use and
disclose protected health information to contact you as a reminder that you
have an appointment with other health providers. [45CFR164.520(b)(1)(iii)]
6. Treatment Alternatives and Other
Health-Related Benefits and Services:
We may use and
disclose protected health information to tell you about or recommend possible
treatment options or alternatives and to tell you about health related
benefits, services, or medical education classes that may be of interest to
you. [45CFR164.520(b)(1)(iii)]
7. Fundraising
Activities:
We may use information about you to contact you in an effort to raise money for FAVARH and its operations. The information we release will be limited to your contact information, such as your name, address and telephone number, the dates you received treatment or services at FAVARH, or photo. A description of how to opt out of receiving any further fundraising communications will be included with any fundraising materials you receive from FAVARH. You have the right to request in writing that your information (including photo) not be used or disclosed for fundraising purposes, in which case, we will make a reasonable effort to comply with your request and to ensure that you do not receive future fundraising communications.
8. Facility
Directory:
We may post limited information for treatment purposes about you in program areas of our facility while you are a participant at FAVARH, including your name, picture, program and/or current general program status. This information may be released to people who ask for you by name. Your information and religious affiliation may also be given to a member of the clergy, even if the clergy member does not ask for you by name. PHI will only be released for individuals admitted to a hospital for psychiatric disabilities or to a substance abuse treatment program, according procedures identified in Section 21 of this document.
9. Individuals Involved in Your Care or Payment of Your Care:
Unless you object, we may disclose your protected health information to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care to notify the person of your location or general condition or payment related to your health care. In addition, we may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.
10. Research Purposes:
Your protected health information may be used or
disclosed for research purposes, but only if the use and disclosure of your
information has been reviewed and you provide authorization. For example, a research project may involve
comparing the progress of all individuals involved in a certain type of program
compared to those in a different program.
All research
projects are subject to a special approval process. This process evaluates a proposed research
project and its use of health information.
Before we use or disclose health information for research, the project
will have been approved through the research approval process. We will ask your permission if the researcher
will have access to your name, address or other information that reveals who
you are, or will be involved in your support.
[45CFR164.512(l)]
12. To Avert A Serious Threat to Health
or Safety:
We may use
and disclose your protected health information when necessary to prevent a
serious threat to your health or safety or the health or safety of the public
or another person. Any disclosure,
however, would be to someone able to help prevent the threat. [45CFR164.512(j)]
13. Workers’
Compensation:
We may use
or disclose your protected health information as permitted by laws relating to
workers’ compensation or related programs. [45CFR164.512(l)]
14. Public
Health Risk:
We may
disclose your protected health information to a public health authority that is
authorized by law to collect or receive such information, such as for the
purpose of preventing or controlling disease, injury, or disability; reporting
births, deaths or other vital statistics; reporting child abuse or neglect;
notifying individuals of recalls of products they may be using; notifying a
person who may have been exposed to a disease or may be at risk of contracting
or spreading a disease or condition; notifying the appropriate government
authority if we believe a person has been the victim of abuse, neglect or
domestic violence. We will only make this
disclosure if you agree or when required or authorized by law. [45CFR164.512(b)&(c )]
15. Health Oversight Activities:
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure and disciplinary actions. These activities are necessary for the government to monitor the health care system, government reimbursed programs, and compliance with civil rights laws. [45CFR164.512(d)]
16. Judicial and Administrative Proceedings:
If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to your authorization, a court or administrative order, or other lawful process if such disclosure is permitted by law. We will disclose the information only if efforts have been made to tell you about the request or to obtain a court order protecting the information requested.
17. Law Enforcement:
We may disclose your protected health information for
certain law enforcement purposes if permitted or required by law. For example, to report gunshot wounds; to
report emergencies or suspicious deaths; to comply with a court order, warrant,
or similar legal process; or to answer certain requests for information
concerning crimes. [45CFR164.512(a)] For
example, we may disclose health information if asked to do so by law
enforcement officials:
§In response to a court order or similar process;
§To identify or locate a suspect, fugitive, material witness, or missing person;
§About the victim of a crime if, under limited circumstances, we are unable to obtain the person’s agreement.
§About a death we believe may be the result of criminal conduct;
§About criminal conduct within one of our programs; and
§In
emergency circumstances to report a crime; the location of the crime or
victims; or the identify, description or location of the person who committed
the crime. [45CFR164.512(f)]
18. Coroners, Medical Examiners,
Funeral Directors, and Organ
Procurement Organizations: We may release your protected
health information to a coroner, medical examiner, funeral director, or, if you
are an organ donor, to an organization involved in the donation of organs and
tissues. [45CFR164.512(g)]
19. Military and National Security:
If required by law, if you are a
member of the armed forces, we may use and disclose your protected health
information as required by military command authorities or the Department of
Veterans Affairs. If required by law, we
may disclosure your protected health information to authorized federal
officials for the conduct of lawful intelligence, counter-intelligence, and
other national security activities authorized by law. If required by law, we may disclose your protected
health information to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state
or conduct special investigations. [45CFR164.512(k)(2)-(3)]
20. Inmates:
If you are an inmate of a correctional institution or
under custody of a law enforcement official, we may disclose health information
about you to the correctional institution of law enforcement official. This disclosure would be necessary:
(1) for
the institution to provide you with health care
(2) to protect your health and safety or the health and safety of others; or
(3)
for the safety and security of
the correctional institution. [45CFR164.512(k)(5)]
21. Special
Rules Regarding Disclosure of Psychiatric, Substance Abuse and HIV-Related
Information:
For disclosures concerning protected health information relating to care for psychiatric conditions, substance abuse or HIV‑related testing and treatment, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or a court orders the disclosure.
Mental
health information. Certain
mental health information may be disclosed for treatment, payment and health
care operations as permitted or required by law. Otherwise, we will only disclose such
information pursuant to an authorization, court order or as otherwise required
by law. For example, all communications between you and a psychologist,
psychiatrist, social worker and certain therapists and counselors will be
privileged and confidential in accordance with
Substance abuse treatment information. If you are treated in a specialized substance abuse program, the confidentiality of alcohol and drug abuse patient records is protected by Federal law and regulations. Generally, we may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser, unless:
1. You consent in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
Violation of these Federal laws and regulations by us is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the substance abuse program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
HIV‑related
information. We may disclose HIV‑related
information as permitted or required by
Minors. We will comply with
22. Other
Uses of Medical Information:
Other uses and disclosures of health information not covered by this notice
or the laws that apply to The Arc of the Farmington Valley, Inc. will be made
only with your written permission. If
you provide us written permission to use and disclose medical information about
you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no
longer use or disclose health information about you for the reasons covered by
your written authorization. You
understand that we are unable to take back any disclosures we have already made
with your permission, and that we are required to retain our records of the
services that we provided you.
When We
May Not Use or Disclose Your Protected Health Information
Except as
described in this Notice, or as permitted by
Psychotherapy Notes
A signed
authorization or court order is required for any use or disclosure of
psychotherapy notes except to carry out certain treatment, payment, or health
care operations and for use by FAVARH for treatment, for training programs, or
for defense in a legal action.
Marketing
A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by FAVARH.
YOUR
RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding health information we
maintain about you: [45CFR164.520(b)(1)(iv)]
I. Right to Access, Inspect and Copy Your Protected Health Information
You
have the right to access, inspect and obtain a copy of your protected health
information that is used to make decisions about your care for as long as the
protected health information is maintained by FAVARH. To access, inspect and copy your protected
health information that may be used to make decisions about you, you must
submit your request in writing to FAVARH.
If you request a copy of the information, we may charge a fee for the
costs of preparing, copying, mailing or other supplies associated with your
request. We may deny, in whole or in
part, your request to access, inspect and copy your protected health
information under certain limited circumstances. If we deny your request, we will provide you
with a written explanation of the reason for the denial. You may have the right to have this denial
reviewed by an independent health care professional designated by us to act as
a reviewing official. This individual
will not have participated in the original decision to deny your request. You may also have the right to request a
review of our denial of access through a court of law. All requirements, court costs and attorney’s
fees associated with a review of denial by a court are your
responsibility. You should seek legal
advice if you are interested in pursuing such rights.
[45CFR164.520(b)(1)(iv) & 45CFR164.524]
II. Right to Amend Your Protected Health Information
You have the right to request an amendment to your protected health information for as long as the information is maintained by or for FAVARH. Your request must be made in writing to FAVARH and must state the reason for the requested amendment. You can obtain a Request for Amendment form from FAVARH. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
We may deny your request if you ask us to amend information that:
§ Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
§ Is not part of the health information kept by or for The Arc of the Farmington Valley, Inc.
§ Is not part of the information which you would be permitted to inspect and copy; or
§ Is accurate and complete.
We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information. [45CFR164.520(b)(1)(iv) & 45CFR164.526]
III. Right to an Accounting of Disclosures
You have the right to request an “accounting of
disclosures.” This is a list of the
disclosures The Arc of the Farmington Valley, Inc. made of your protected
health information that is not addressed by this Notice of Privacy Practices.
To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer of The Arc of the Farmington Valley, Inc. Your request:
§ Must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.
§ Should indicate in what form you want the list (for example, on paper, or electronically).
The first list
you request within a 12 month period will be free. For additional lists, The Arc of the
Farmington Valley, Inc. may charge you for the cost of providing the list. We will notify you of the cost involved and
you may choose to withdraw or modify your request at that time before any costs
are incurred. [45CFR164.520(b)(1)(iv) & 45CFR164.528]
IV. Right
to Request Restrictions:
You have the right to request certain restrictions or
limitations on the protected health information we use or disclose about
you. You may request a restriction or
revise a restriction on the use or disclosure of your protected health
information by providing a written request stating the specific restriction
requested. You can obtain a Request for
Restriction form from FAVARH.
We are not required to agree to your request. If we do
agree, we will comply with your request unless the information is needed to
provide you emergency treatment. If
restricted protected health information is disclosed to a health care provider
for emergency treatment, we will request that such health care provider not
further use or disclose the information.
In addition, you and FAVARH may terminate the restriction if the other
party is notified in writing of the termination. Unless you agree, the termination of the
restriction is only effective with respect to protected health information
created or received after we have informed you of the termination. For example, you could ask that we not use or
disclose information about past medical information.
To request restrictions, you must make your request in
writing to the The Arc of the Farmington Valley, Inc. Privacy Officer. In your request, you must tell us:
(1) What information you want to limit;
(2) Whether you want to limit our use of said information, or
the disclosure of said information, or both; and
(3) To whom you want limits to apply, for example, disclosures to your spouse.
[45CFR164.520(b)(1)(iv) &
45CFR164.522]
V. Right to Request Confidential Communications:
You have the
right to request a reasonable accommodation regarding how you receive
communications of protected health information.
You have the right to request an alternative means of communication or
an alternative location where you would like to receive communications. You may submit a request in writing to FAVARH
requesting confidential communications.
You can obtain a Request for Confidential Communications form from
FAVARH. [45CFR164.520(b)(1)(iv)]
VI. Right to a Paper Copy of this
Notice:
You have the right to obtain a paper copy of this
Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any
time by contacting FAVARH. In addition,
you may obtain a copy of this Notice at our web site, http://www.favarh.org To obtain a paper copy of this notice you can
contact the The Arc of the Farmington Valley, Inc. Privacy Officer. [45CFR164.520(b)(1)(iv) &
45CFR164.530]
You may file a
complaint with us or the Secretary of Health and Human Services if you believe
your privacy rights have been violated by us.
You may file a complaint with us by notifying our Privacy Officer of
your complaint. You will not be
penalized for filing a complaint and we will make every reasonable effort to
resolve your complaint with you.
If you believe your
privacy rights have been violated, you may file a complaint with The Arc of the
Farmington Valley, Inc., the Department of Mental Retardation, or the Secretary
of the Department of Health and Human Services.
To file a complaint with The Arc of the Farmington Valley, Inc., contact
the Privacy Officer of The Arc of the Farmington Valley, Inc. at
860-693-6662. All complaints must be
submitted in writing to The Arc of the Farmington Valley, Inc.,
You will not be penalized for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right
to change this notice. We reserve the
right to make the revised or changed notice effective for health information we
already have about you as well as about any information we receive about you in
the future. We will post a copy of the
current notice in our facilities. The
notice will contain on the first page, in the top right-hand corner, the
effective date. In addition, each time
you receive new services from us, we will offer you a copy of the current
notice in effect. [45CFR164.520(b)(3)]
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to The Arc of the Farmington Valley, Inc. will be made only with your written permission. If you provide us written permission to use and disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the services that we provided you.
CONTACTS FOR FURTHER INFORMATION
If you have any questions about this notice please contact the Privacy Officer at The Arc of the Farmington Valley, Inc. Department Directors of The Arc of the Farmington Valley, Inc. can also assist you.
The
Arc of the Farmington Valley, Inc.