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Notices 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.
Important Notice of Privacy Practices
WEST HAVEN COMMUNITY HOUSE
It is important to read and understand this Notice of Privacy
Practices 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 the West
Haven Community House Privacy Officer.
WEST HAVEN COMMUNITY HOUSE
Patricia Stevens
WHCH Privacy Officer
227 Elm Street
West Haven, CT 06516
(203) 934-5221
Notice of Privacy Practices
Effective Date: April 14, 2003
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” 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 contact the WEST HAVEN
COMMUNITY HOUSE (“WHCH”).
How We May Use or Disclose Your Protected Health
Information
WHCH will ask you to sign a consent form that allows WHCH 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, WHCH 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.
- For Treatment - We 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 WHCH and for other treatment reasons. We may
also use or disclose your protected health information in an
emergency situation.
- For 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, or another third party
payer. For example, we may need to give your child care
assistance program information about the service you received so
your payer will pay us or reimburse us for the service, or we
may contact your child care assistance program to confirm your
coverage or to request prior authorization for a proposed
service.
- For Health Care Operations - We may use and
disclose your health information as necessary for operations of
WHCH, 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 WHCH.
- Business Associates - There may be some
services provided by our business associates, such as 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.
- Appointment Reminders - We may use and
disclose protected health information to contact you as a
reminder that you have an appointment at WHCH.
- 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.
- Fundraising Activities - We may use
information about you to contact you in an effort to raise money
for WHCH and its operations. The information we release will be
limited to your contact information, such as your name, address
and telephone number and the programs you are involved in at
WHCH.. If you request that your information not be used or
disclosed for fundraising purposes, we will make a reasonable
effort to ensure that you do not receive future fundraising
communications.
- 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.
- Public Health Activities - 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.
- 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.
- 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 or a court or administrative order. We may also
disclose your protected health information in response to a
subpoena, discovery request, or other lawful process if such
disclosure is permitted by law.
- 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.
- Coroners, Medical Examiners, Funeral Directors,
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.
- 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 approved by a special Privacy Board or
Institutional Review Board, or if you provide authorization.
- 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.
- 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.
- Workers’ Compensation - We may use or
disclose your protected health information as permitted by laws
relating to workers’ compensation or related programs.
- 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 Connecticut and Federal law.
- 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 Connecticut
law. For example, your HIV-related information, if any, may be
disclosed without your authorization for treatment purposes,
certain health oversight activities, pursuant to a court order,
or in the event of certain exposures to HIV by personnel of
WHCH, another person, or a known partner.
- Minors. We will comply with Connecticut law
when using or disclosing protected health information of minors.
For example, if you are an unemancipated minor consenting to a
health care service related to HIV/AIDS, venereal disease,
abortion, outpatient mental health treatment or alcohol/drug
dependence, and you have not requested that another person be
treated as a personal representative, you may have the authority
to consent to the use and disclosure of your health information.
When We May Not Use or Disclose Your Protected Health
Information
Except as described in this Notice, or as permitted by Connecticut
or Federal law, we will not use or disclose your protected health
information without your written authorization.
Your written authorization will specify particular uses or
disclosures that you choose to allow. Under certain limited
circumstances, WHCH may condition treatment on the provision of an
authorization, such as for research related to treatment. If you do
authorize us to use or disclose your protected health information
for reasons other than treatment, payment or health care operations,
you may revoke your authorization in writing at any time by
contacting WHCH’s Privacy Officer. If you revoke your authorization,
we will no longer use or disclose your protected health information
for the purposes covered by the authorization, except where we have
already relied on the authorization.
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 WHCH
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 WHCH.
Your Health Information Rights
You have the following rights with respect to your protected health
information. The following briefly describes how you may exercise
these rights.
- Right to Request Restrictions of Your Protected
Health Information - 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 WHCH. We are not required to
agree to your requested restriction. If we do agree to accept
your requested restriction, we will comply with your request
except as needed to provide you with 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 WHCH 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.
- Right to Receive 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 WHCH requesting confidential communications. You can obtain a
Request for Confidential Communications form from WHCH.
- 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 WHCH. 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 WHCH. 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.
- 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 WHCH. Your request must be made in writing to WHCH and
must state the reason for the requested amendment. You can
obtain a Request for Amendment form from WHCH. 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 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.
- Right to Receive An Accounting of Disclosures of
Protected Health Information - You have the right to
request an accounting of certain disclosures of your protected
health information by WHCH or by others on our behalf. To
request an accounting of disclosures, you must submit a request
in writing, stating a time period beginning on or after April
14, 2003 that is within six (6) years from the date of your
request. The first accounting provided within a twelve-month
period will be free. We may charge you a reasonable, cost-based
fee for each future request for an accounting within a single
twelve-month period. However, you will be given the opportunity
to withdraw or modify your request for an accounting of
disclosures in order to avoid or reduce the fee.
- Right to Obtain A Paper Copy of 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
WHCH.
- Right to Complain - 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.
WEST HAVEN COMMUNITY HOUSE
Patricia Stevens
WHCH Privacy Officer
227 Elm Street
West Haven, CT 06516
(203) 934-5221
Consent and Acknowledgment Form
I consent to the use or disclosure of my protected health
information by WEST HAVEN COMMUNITY HOUSE (“WHCH”) to any person or
organization for the purposes of carrying out treatment, obtaining
payment or conducting certain healthcare operations. Protected
health information used or disclosed by WHCH may include HIV/AIDS
related information, psychiatric and other mental health
information, and drug and alcohol treatment information, as long as
such information is used or disclosed in accordance with Connecticut
and Federal law, which may require you to provide specific
authorization. I understand that information regarding how WHCH will
use and disclose my information can be found in WHCH’s Notice of
Privacy Practices. I understand that this consent is effective for
as long as WHCH maintains my protected health information.
By signing below, I understand and acknowledge the following:
- I have read and understand this consent; and
- I have received WHCH’s Notice of Privacy Practices currently
in effect.
Print Name of West Haven Community House participant
___________________________________________________
Print Name of Individual or Personal Representative who will be
signing
__________________________________________________
Signature of Individual or Personal Representative Date
If signed by the individual’s representative, describe the legal
authority of the representative to act on behalf of the individual,
i.e. parent, guardian, etc.
___________________________________________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * *
For WHCH use only:
Unable to obtain written consent and acknowledgment because:
□ Individual refused
□ Emergency treatment situation
□ Individual not able to sign due to incompetence or other medical
reason
□ Other: ______________________________________
