Effective: March 1, 2014
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.
This notice will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. In this notice, we call all of that protected health information, “medical information.”
This notice also will tell you about your rights and our duties with respect to medical information about you. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
How We May Use and Disclose Medical Information About You
We use and disclose medical information about you for a number of different purposes. Each of those purposes is described below.
• For Treatment
We may use medical information about you to provide, coordinate or manage your health care and related services by both us and other health care providers. We may disclose medical information about you to doctors, nurses, hospitals and other health facilities who become involved in your care. We may consult with other health care providers concerning you and as part of the consultation share your medical information with them. Similarly, we may refer you to another health care provider and as part of the referral share medical information about you with that provider. For example, we may conclude you need to receive services from a physician with a particular specialty. When we refer you to that physician, we also will contact that physician’s office and provide medical information about you to them so they have information they need to provide services for you.
• For Payment
We may use and disclose medical information about you so we can be paid for the services we provide to you. This can include billing a third party payor or other state agency, or your insurance company. For example, we may need to provide the state Medicaid program information about the services we provide to you so we will be reimbursed for those services. We also may need to provide the state Medicaid program with information to ensure you are eligible for the medical assistance program.
• For Health Care Operations
We may use and disclose medical information about you for our own health care operations. These are necessary for us to operate ACT and to maintain quality for the individuals for whom we provide supports and services. For example, we may use medical information about you to review the services we provide and the performance of our employees supporting you. We may disclose medical information about you to train our staff and volunteers. We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program.
• How We Will Contact You
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate to you in a certain way or at a certain location, see “Right to Receive Confidential Communications”.
• ACT Directory
We may include your name, your location in our facility, your condition described in general terms, and your religious affiliation, in our directory while you receive services. This information, except for your religious affiliation may be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, such as a minister, priest or rabbi. If you do not want included in our facility directory, or you want to restrict the information we include in the directory, you must notify your Program Director of your objection.
• Individuals Involved in Your Care
We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, medical information about you that is directly relevant to that person’s involvement with the services and supports you receive or payment for those services and supports. We also may use or disclose medical information about you to notify, or assist in notifying, those persons of your location, general condition, or death. In the event of your death, we may disclose to any of those persons who were involved in your care for payment for health care prior to your death, medical information about you that is relevant to that person’s involvement, unless doing so is inconsistent with any prior expressed preference of you that is known to us.
If there is a family member, other relative, or close personal friend that you do not want us to disclose medical information about you to, please notify your Program Director or tell our staff member who is providing care to you.
• Disaster Relief
We may use or disclose medical information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. This will be done to coordinate with those entities in notifying a family member, other relative, close personal friend, or other person identified by you, of your location, general condition or death.
• Required by Law
We may use or disclose medical information about you when we are required to do so by law.
• Public Health Activities
We may use or disclose medical information about you for public health activities and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.
• To an Employer
We may use or disclose medical information to your employer if: (a) we provide health care to you at the request of your employer to conduct an evaluation relating to medical surveillance of the workplace or to evaluate if you have a work related illness or injury; (b) the information disclosed will consist of findings concerning a work related illness or injury or a workplace related medical surveillance; (c) the employer needs the findings in order to comply with its legal obligations to record the illness or injury or to carry out its responsibilities for workplace medical surveillance. We will provide written notice to you that the information is being disclosed to your employer. The written notice may be given at the time the health care is provided or, if the health care is provided at your employer’s work site, by posting the notice at the location where the health care is provided.
• Proof of Immunization
We may use or disclose immunization information to a school about you: (a) if you are a student or prospective student of the school; (b) the information is limited to proof of immunization; (c) the school is required by State or other law to have the proof of immunization prior to admitting you; and, (d) we obtain and document the agreement to the disclosure from either: (1) your parent, guardian, or other person standing in loco parentis of you if you are an unemancipated minor, or (2) from you if you are an adult or an emancipated minor.
• Victims of Abuse, Neglect or Domestic Violence
We may disclose medical information about you to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you; or, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or, if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
• Health Oversight Activities
We may disclose medical information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.
• Judicial and Administrative Proceedings
We may disclose medical information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal. We also may disclose medical information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.
• Disclosures for Law Enforcement Purposes
We may disclose medical information about you to a law enforcement official for law enforcement purposes: (a) as required by law; (b) in response to a court, grand jury or administrative order, warrant or subpoena; (c) to identify or locate a suspect, fugitive, material witness or missing person; (d) about an actual or suspected victim of a crime and that person agrees to the disclosure (if we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed); (e) to alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct; (f) about crimes that occur at our facility; (g) to report a crime in emergency circumstances.
• Coroners and Medical Examiners
We may disclose medical information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death.
• Funeral Directors
We may disclose medical information about you to funeral directors as necessary for them to carry out their duties.
• Organ, Eye or Tissue Donation
To facilitate organ, eye or tissue donation and transplantation, we may disclose medical information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue.
Under certain circumstances, we may use or disclose medical information about you for research. Before we disclose medical information for research, the research will have been approved through an approval process that evaluates the needs of the research project with your needs for privacy of your medical information. We may, however, disclose medical information about you to a person who is preparing to conduct research to permit them to prepare for the project, but no medical information will leave ACT during that person’s review of the information.
• To Avert Serious Threat to Health or Safety
We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.
If you are a member of the Armed Forces, we may use and disclose medical information about you for activities deemed necessary by the appropriate military command authorities to assure the proper execution of the military mission. We may also release information about foreign military personnel to the appropriate foreign military authority for the same purposes.
• National Security and Intelligence
We may disclose medical information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law.
• Protective Services for the President
We may disclose medical information about you to authorized federal officials so they can provide protection to the President of the United States, certain other federal officials, or foreign heads of State, or to conduct investigations authorized by certain federal laws.
• Security Clearances
We may use medical information about you to make medical suitability determinations and may disclose the results to officials in the United States Department of State for purposes of a required security clearance or service abroad.
• Inmates; Persons in Custody
We may disclose medical information about an inmate or other individual to a correctional institution or law enforcement official having custody of the inmate or other individual. The disclosure will be made if the disclosure is necessary: (a) to provide health care to such individuals; (b) for the health and safety of such individual or other inmates; (c) the health and safety of the officers or employees of or others at the correctional institution; (d) the health and safety of such individuals and officers or other persons responsible for the transporting of inmates or their transfer from one institution, facility, or setting to another; (e) law enforcement on the premises of the correctional institution; or, (f) the administration and maintenance of the safety, security, and good order of the correctional institution.
• Workers Compensation
We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
We may use and disclose medical information about you to contact you to raise funds for ACT. We may disclose medical information to a business associate of ACT or a foundation related to ACT so that business associate or foundation may contact you to raise money for the benefit of ACT. We will only release: (a) demographic information relating to you, including your name, address, other contact information, age, gender, and date of birth; (b) dates of health care provided to you; (c) department of service information; (d) treating physician; (e) outcome information; and, (f) health insurance status.
You have the right to opt out of receiving fundraising communications. If you do not want ACT or its foundation to contact you for fundraising, you must notify your Program Director.
Certain Uses and Disclosures that Require Your Written Authorization
• Psychotherapy Notes
Your authorization is required before we may use or disclose psychotherapy notes unless the use or disclosure is: (a) by the originator of the psychotherapy notes for treatment; (b) for our own training programs for students, trainees, or practitioners in mental health; (c) to defend ourselves in a legal action or other proceeding brought by you; (d) when required by law; or, (e) permitted by law for oversight of the originator of the psychotherapy notes.
We may use and disclose medical information about you to communicate with you about a product or service to encourage you to purchase the product or service. Generally, this may occur without your authorization. However, your authorization is required if: (a) the communication is to provide refill reminders or otherwise communicate about a drug or biologic that is, at the time, being prescribed for you and we receive any financial remuneration in exchange for making the communication which is not reasonably related to our cost in making the communication; or, (b) except as stated in (a), we use or disclose your medical information for marketing purposes and we receive direct or indirect financial remuneration from a third party for
doing so. When an authorization is required to communicate with you about a product or service to encourage you to purchase the product or service, the authorization will state that financial remuneration to ACT is involved.
• Sale of Information
Your authorization is required for any disclosure of your medical information when the disclosure is in exchange for direct or indirect remuneration from or on behalf of the recipient of the medical information. However, your authorization may not be required under certain conditions if the disclosure is: (a) for public health purposes; (b) for research purposes; (c) for treatment and payment; (d) if we are being sold, transferred, merged or consolidated; (e) to a business associate of ours for activities undertaken on our behalf; (f) to you when requested by you; (g) required by law; (h) when permitted by applicable law where the only remuneration received by us is a fee permitted by law.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying your Program Director in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Medical Information About You.
You have the following rights with respect to medical information that we maintain about you.
• Right to Request Restrictions
You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) for to public or private entities for disaster relief efforts. For example, you could ask that we not disclose medical information about you to your brother or sister.
To request a restriction, you may do so at any time. If you request a restriction, you should do so in writing to your Program Director and tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your spouse).
With one exception, we are not required to agree to any requested restriction.
The exception is that we will always agree to a request to restrict disclosures to a health plan if: (a) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and, (b) the information relates solely to a health care item or service for which you, or someone on your behalf (other than the health plan), has paid us in full.
• Right to Receive Confidential Communications
You have the right to request that we communicate medical information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication
If we agree to a restriction, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction. However, we will not terminate a restriction that falls into the exception stated in the previous paragraph.
We will accommodate your request. However, we may, when appropriate, require information from you concerning how payment will be handled. We also may require an alternate address or other method to contact you.
If you want to request confidential communication, you must do so in writing to your Program Director. Your request must state how or where you can be contacted.
• Right to Inspect and Copy
With a few very limited exceptions, such as psychotherapy notes, you have the right to inspect and obtain a copy of medical information about you.
To inspect or copy medical information about you, you must submit your request in writing to your Program Director. Your request should state
specifically what medical information you want to inspect or copy. Your request should state the form of access and copy you desire, such as in paper or in electronic media. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed, the cost of mailing.
We usually will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.
We may deny your request to inspect and copy medical information if the medical information involved is: (a) psychotherapy notes; (b) information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding.
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.
• Right to Amend
You have the right to ask us to amend medical information about you. You have this right for so long as the medical information is maintained by us.
To request an amendment, you must submit your request in writing to your Program Director. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the medical information by appending or otherwise providing a link to the amendment.
We may deny your request to amend medical information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend medical information if we determine that the information: (a) was not created by us, unless the person or entity that created the information is no longer available to act on the requested amendment; (b) is not part of the medical information maintained by us; (c) would not be available for you to inspect or copy; or, (d) is accurate and complete.
If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreeing with our denial. Your statement may not exceed two (2) pages. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the medical information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the medical information involved.
You also will have the right to complain about our denial of your request.
• Right to an Accounting of Disclosures
You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting: (a) disclosures to carry out treatment, payment and health care operations; (b) disclosures of your medical information made to you; (c) disclosures that are incident to another use or disclosure; (d) disclosures that you have authorized; (e) disclosures for our facility directory or to persons involved in your care; (f) disclosures for disaster relief purposes; (g) disclosures for national security or intelligence purposes; (h) disclosures to correctional institutions or law enforcement officials having custody of you; (i) disclosures that are part of a limited data set for purposes of research, public health, or health care operations (a limited data set is where things that would directly identify you have been removed); (j) disclosures made prior to April 14, 2003.
Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official to a health oversight agency.
To request an accounting of disclosures, you must submit your request in writing to your Program Director. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and may not include dates before April 14, 2003.
Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.
• Right to Copy of this Notice
You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even if you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time.
To obtain a paper copy of this notice, contact your Program Director.
We are required by law to maintain the privacy of medical information about you, to provide individuals with notice of our legal duties and privacy practices with respect to medical information, and to notify affected individuals following a breach of unsecured protected health information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.
• Our Right to Change Notice of Privacy Practices
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the effective date of the new notice.
• Availability of Notice of Privacy Practices
A copy of our current Notice of Privacy Practices will be posted in the break rooms maintained in ACT office facilities at 2200, 2205, and 2207 Burlington and any future locations in which we offer services. A copy of the current notice also will be posted on our web site, www.actservices.org
At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting your Program Director.
• Effective Date of Notice
The effective date of the notice is stated on the first page of this notice.
You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
To file a complaint with us, contact your Program Director. All complaints should be submitted in writing.
To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201. Complaints also may be filed online.
You will not be retaliated against for filing a complaint.
• Questions and Information
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact your Program Director.