NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW MENTAL AND PHYSICAL HEALTH INFORMATION ABOUT YOU* MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
What This Notice Contains: This notice will tell you how, when and why we may use and disclose your Protected Health Information (PHI). Protected Health Information means any health information about you that identifies you or for which there is reasonable basis to believe the information can be used to identify you. This notice will also tell you about your rights and our duties with respect to your Protected Health Information. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
Our Commitment to Privacy: We will protect the privacy of the PHI that we maintain that identifies you, whether it deals with the provision or payment of your health care. With some exceptions, we will avoid using or disclosing any more of your PHI than is necessary to accomplish the purpose of the use of disclosure. We are legally required to follow the privacy practices that are described in this Notice, which are currently in effect.
We are required by law to make sure that mental and physical health information that identifies you is kept private and to give you this notice of our legal duties and privacy practices with respect to mental and physical health information about you.
* You may refer to yourself, your child, your family or any other person participating in your treatment.
Protected Health Information is used for a number of purposes:
Uses and disclosures relating to treatment, payment or health care operations
For treatment
We may use PHI about you to provide, coordinate or manage your
health care and related services by our agency and other health
care providers. For example, we may disclose your PHI to another
health care provider or agency related to linkage or referral,
such as to a residential care program. Such disclosure may be to
provide them the medical history information they need to
appropriately treat your condition, to coordinate your care, or
to schedule necessary testing.
To obtain payment
for treatment
We may use and disclose PHI about you so that we can be paid for
the services we provide to you. For example, we may provide
certain portions of your PHI to your health insurance company,
Medicaid or Medicare, managed care entity, or community mental
health entity in order to get paid for taking care of you. With
the possible exception of information concerning drug and
alcohol abuse and/or treatment, and HIV status (for which we may
need your specific authorization), we may use and disclose
necessary PHI in order to bill and collect payment for the
treatment that we have provided you.
For health care
operations
We may, at times, need to use and disclose your PHI to run our
organization. For example, we may use your PHI to evaluate the
quality of the treatment that our staff has provided. We may
also need to provide some information to our accountants,
attorneys, and consultants in order to make sure that we’re
complying with law.
Uses and disclosures permitted by federal law without authorization
When required by
federal, state, or local law, in judicial or administrative
proceedings, or by law enforcement
For example we may disclose your PHI if a court orders us to, or
if a law requires that we report that sort of information to a
government or law enforcement authority.
For public health
activities
Under the law, we need to report medical information to a public
health authority authorized to collect or receive the
information for purposes of preventing or controlling disease.
We may disclose PHI about you to a government authority
authorized by law to receive reports of abuse or neglect if we
believe you are a victim of abuse or neglect or if we suspect
that you have abused or neglected someone.
For health oversight
activities
We may need to provide your PHI to a county or state agency when
they oversee the program in which you receive care. If your
health care record is selected for audit or inspection, we may
need to provide access to your PHI. We may also need to provide
information to governmental agencies that have the right to
inspect our offices and/or investigate health care practices.
To avoid harm
If one of our staff members believes that it is necessary to
protect you, or to protect another person or the public as a
whole, we may provide PHI to the police or others.
For Workers’
Compensation
We may provide your PHI as described under the Workers’
Compensation law, if your condition was the result of a
workplace injury for which you are seeking Workers’
Compensation.
Appointment
reminders
Unless you tell us that you would prefer not to receive them, we
may use or disclose your PHI to provide you with appointment
reminders.
You Have the Opportunity to Object to Certain Uses and Disclosures:
Disclosures to
family, friends, or others involved in your care
We may disclose a limited amount of your PHI to a family member,
friends, or other person known to be involved in your care or in
the payment of your care, unless you tell us not to. For
example, if a family member comes with you to your appointment
and you allow them to come into the treatment room with you, we
may disclose otherwise private information to them during the
appointment, unless you tell us not to. If there is family
member, other relative, or close personal friend that you do not
want us to disclose PHI about you, please notify the staff
member who is providing care to you or the Privacy Officer.
Disclosures to
notify a family member, friend or other selected member
When you first started in our program, we asked you to provide
us with an emergency contact person should anything happen to
you while you are at our facilities. Unless you tell us
otherwise, we will disclose limited PHI about you (your general
condition, location, etc.) to your emergency contact or another
available family member.
Some uses and
disclosures require your prior written authorization
In situations other than those mentioned above, or those
disclosures permitted under federal law, we will ask your
written authorization before using or disclosing any of your
PHI.
If you choose to sign an authorization to disclose any of your PHI, you can later revoke it to stop further uses and disclosures to the extent that we haven’t already taken action relying on the authorization, so long as it is revoked in writing (except for people receiving drug and alcohol services, when a verbal revocation is accepted).
For example, if we wish to use any of your PHI for any of the following activities we would need your written authorization: coordination of services, public relations, fundraising, or research.
Your Rights With Respect To Protected Health Information:
The right to request
limits on uses and disclosures of your PHI
You have the right to ask us to limit how we use and disclose
your PHI. We will certainly consider your request, but you
should know that we are not required to agree to it. If we do
agree to your request, we will put the limits in writing and
will abide by them, except in the case of an emergency. Please
note that you are not permitted to limit the uses and
disclosures that we are required or allowed by law to make.
To request a restriction,
please contact the Privacy Officer and tell us:
a) what information you want to limit
b) whether you want to limit use, disclosure or both
c) to whom you want the limits to apply
The right to choose
how we send PHI to you or how we contact you
You have the right to ask that we contact you at an alternate
address or telephone number (i.e., sending information to your
work address instead of your home address) or by alternate
means. We must agree to your request as long as it is
reasonable. Requests must be made in writing to the Privacy
Officer.
The right to see or to
get a copy of your PHI
In most cases, you have the right to look at or get a copy of
your PHI. Your request must be made in writing on a request form
available at your location of service or by contacting the
Privacy Officer. State specifically what PHI you want to look
at or copy. You can expect to receive a response within 30 days
following receipt of your written request. If your request is
accepted in whole or part, we will contact you and provide
access and copies. If your request is denied, we will inform you
of the basis for denial, how you may have the denial reviewed,
and how to submit a complaint. Review of denials will be
conducted by a licensed health care professional, designated by
the Agency, who was not directly involved in the denial. We will
comply with the outcome of that review.
Copies of any portion of your PHI may be requested. A per page copy charge will be assessed and payment in full is required before copies will be provided.
The right to receive
a list of certain disclosures that we have made of your PHI
You have the right to get a list of certain types of disclosures
that we have made of your PHI. This list would not include uses
or disclosures for treatment, payment or health care operations,
disclosures to you with your written authorization, or
disclosures to your family for notification purposes or due to
their involvement in your care. This list would also not include
any disclosures made for national security purposes, disclosures
to corrections or law enforcement authorities if you were in
custody at the time, or disclosures made prior to April 14,
2003. You may not request an accounting for longer than a six
(6) year period.
Requests must be received in writing on a request form available at your location of service or by contacting the Privacy Officer. A response will be made within 60 days of receiving your request. The list that you may receive will include the date of the disclosure, the person or organization that received the information (with address if available), a brief description of information disclosed, and reason for the disclosure. This list will be provided to you at no charge. More than one request in the same calendar year will be charged at the rate of $30 for each additional request that year.
The Right to Ask to
Correct or Update Your PHI
If you believe that there is a mistake in your PHI or that a
piece of important information is missing, you have the right to
ask that we make an appropriate change to your information.
Requests must be received in writing stating the reason for the
request. Request forms are available at your location of service
or by contacting the Privacy Officer.
A response will be made within 60 days of receiving your request. If approved, the Agency will make the change to your PHI, tell you when we have done so, and tell others that need to know about the change.
Your request may be denied if the PHI:
a) is already accurate and
complete
b) was not created by us unless the person or entity who created
the information is no longer available to make the amendment
c) is not allowed to be disclosed to you
d) is not part of our records
Written denial will state the reasons that your request was denied and explain your right to file a written statement of disagreement with our denial. We may prepare a rebuttal to that statement. All requests, denials, statements of disagreement, and rebuttals will be added to your PHI and be included with any subsequent disclosures. You have the right to complain about our denial of your request.
Changes to notice of
privacy practices
Family & Children Services reserves the right to change the
terms of this Notice and our privacy practices at any time. Any
changes that are made will apply to any of your PHI that we
already have. Before we make a significant change to our
policies, we will change this Notice and post a new Notice in
your location of service. At any time, you may request a copy of
our Notice of Privacy Practices by calling our Privacy Officer.
You may view and obtain an electronic copy of this Notice on our
website at www.fcsource.org.
Questions and Information: If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the Privacy Officer.
Complaints: You may complain to us or to the United States Secretary of Health and Human Services if you believe that your privacy rights have been violated by us. To file a complaint with us, please contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Protected Health Information
Inquiries:
Privacy Officer
1608 Lake Street
Kalamazoo, MI 49001
tel. 269.344.0202
Family & Children Services seeks to support, strengthen and preserve the safety, well-being and dignity of children, individuals and families through a continuum of human services.
All facilities of Family & Children Services are barrier-free.
