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
BRISTOL ADULT RESOURCE CENTER, INC.
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 Bristol ARC.
BRISTOL ADULT RESOURCE CENTER, INC.
Privacy Officer
P.O. Box 726
621 Jerome Avenue
Bristol, CT 06011-0726
Phone: (860) 582-9102
Fax: (860) 582-8280
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 access our web site at www.bristolarc.org, contact BRISTOL ADULT
RESOURCE CENTER, INC. (“Bristol ARC”) or ask at your next meeting. How
We May Use or Disclose Your Protected Health Information Bristol ARC
will ask
you to sign a consent form that allows Bristol ARC 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,
Bristol ARC
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, 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 Bristol ARC and for other treatment reasons. We may also use or
disclose
your protected health information in an emergency situation. -2- • 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 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 Health Care Operations - We may use and disclose your
health
information as necessary for operations of Bristol ARC, 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 Bristol
ARC. •
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. • Appointment Reminders - We may use and disclose protected
health information to contact you as a reminder that you have an appointment at
Bristol ARC. • 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 Bristol ARC and its
operations. The information we release will be limited to your contact
information, such as your name, address and telephone number and the dates you
received treatment or services at Bristol ARC. If you wish that your information
not be used or disclosed for fundraising purposes, contact Bristol ARC’s
Privacy Office. We will make a reasonable effort to ensure that you do not
receive future fundraising communications. • Program Listings - Except for
individuals admitted to a hospital for psychiatric disabilities or to a
substance abuse treatment program, unless you object, we may include limited
information about you in our program listings while you are a client at the
agency, including your name and location in the facility. The program listings
information, except for your religious affiliation, 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. -3- • 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.
-4- • 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 disclose 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. -5- • 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 Bristol ARC, 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, Bristol ARC 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 Bristol ARC’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 Bristol ARC 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 Bristol ARC. -6- 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 Bristol ARC. 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 Bristol ARC 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 Bristol
ARC requesting confidential communications. You can obtain a Request
for
Confidential Communications form from Bristol ARC. • 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 Bristol ARC. 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 Bristol ARC. 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. -7- • 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 Bristol ARC.
Your request
must be made in writing to Bristol ARC and must state the reason for
the
requested amendment. You can obtain a Request for Amendment form from
Bristol
ARC. 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 Bristol ARC 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 Bristol ARC. In addition, you
may
obtain a copy of this Notice at our web site, www.bristolarc.org. •
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. BRISTOL ADULT RESOURCE
CENTER, INC. Privacy Officer P.O. Box 726 621 Jerome Avenue Bristol, CT
06011-0726 Phone: (860) 582-9102 Fax: (860) 582-8280