HIPPA Privacy Practices The Children’s Home NOTICE OF PRIVACY PRACTICES For parents/guardians • Effective Date _4/11/03_ THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU AND/OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by law to maintain the privacy of your and/or your child’s health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your and/or your child’s health information; and to abide by the terms of the Notice that are currently in effect. I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS The following lists various ways in which we may use or disclose your and/or your child’s health information for purposes of treatment, payment and health care operations. For Treatment. We will use and disclose your and/or your child’s health information in providing you and/or your child with treatment and services and coordinating your and/or your child’s care and may disclose information to other providers involved in your and/or your child’s care. Your and/or your child’s health information may be used by doctors involved in your and/or your child’s care and by other clinicians as well as by physical therapists, pharmacists, suppliers of medical equipment or other persons involved in your and/or your child’s care. For example, we may contact your and/or your child’s physician to discuss your and/or your child’s plan of care. For Payment. We may use and disclose your and/or your child’s health information for billing and payment purposes. We may disclose your and/or your child’s health information to your and/or your child’s representative, or to an insurance or managed care company, Medicare, Medicaid or another third party payer. For example, we may contact Medicare or your and/or your child’s health plan to confirm your and/or your child’s coverage or to request prior approval for services that will be provided to you and/or your child. For Health Care Operations. We may use and disclose your and/or your child’s health information as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor our quality of care. We may disclose your and/or your child’s health information to another entity with which you and/or your child have or had a relationship if that entity requests your and/or your child’s information for certain of its health care operations or health care fraud and abuse detection or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services. II. SPECIFIC USES AND DISCLOSURES OF YOUR AND/OR YOUR CHILD’S HEALTH INFORMATION The following lists various ways in which we may use or disclose your and/or your child’s health information. Individuals Involved in Your and/or your child’s Care or Payment for Your and/or your child’s Care. Unless you object, we may disclose health information about you and/or your child to a family member, close personal friend or other person you identify, including clergy, who is involved in your and/or your child’s care. Emergencies. We may use or disclose your and/or your child’s health information as necessary in emergency treatment situations. As Required By Law. We may use or disclose your and/or your child’s health information when required by law to do so. Business Associates. We may disclose your and/or your child’s protected health information to a contractor or business associate who needs the information to perform services for the Provider. Our business associates are committed to preserving the confidentiality of this information. Public Health Activities. We may disclose your and/or your child’s health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting child abuse or neglect or reporting births and deaths. Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you and/or your child have been a victim of abuse, neglect or domestic violence, we may use and disclose your and/or your child’s health information to notify a government authority, if authorized by law or if you agree to the report. Health Oversight Activities. We may disclose your and/or your child’s health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system. To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your and/or your child’s health or safety or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to someone able to help lessen or prevent the threatened harm. Judicial and Administrative Proceedings. We may disclose your and/or your child’s health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information. Law Enforcement. We may disclose your and/or your child’s health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes. Research. We may use or disclose your and/or your child’s health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your and/or your child’s death, or if you authorize the use or disclosure. Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your and/or your child’s health information to a coroner, medical examiner, and funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue. Disaster Relief. We may disclose health information about you and/or your child to a disaster relief organization. Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations. Workers' Compensation. We may use or disclose your and/or your child’s health information to comply with laws relating to workers' compensation or similar programs. Inmates/Law Enforcement Custody. If you and/or your child are under the custody of a law enforcement official or a correctional institution, we may disclose your and/or your child’s health information to the institution or official for certain purposes including the health and safety of you and/or your child and others. Fundraising Activities. We may use certain limited information to contact you and/or your child in an effort to raise funds for the Provider and its operations. Appointment Reminders. We may use or disclose health information to remind you and/or your child about appointments. Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your and/or your child’s health information to inform you and/or your child about treatment alternatives and health-related benefits and services that may be of interest to you and/or your child. III. USES AND DISCLOSURES WITH YOUR AUTHORIZATION Except as described in this Notice, we will use and disclose your and/or your child’s health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your and/or your child’s health information for the purposes covered by that Authorization, except where we have already relied on the Authorization. IV. YOUR RIGHTS REGARDING YOUR AND/OR YOUR CHILD’S HEALTH INFORMATION Listed below are your rights regarding your and/or your child’s health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to the Provider. At your request, the Provider will supply you with the appropriate form to complete. You have the right to: Request Restrictions. You have the right to request restrictions on our use or disclosure of your and/or your child’s health information for treatment, payment, or health care operations. You also have the right to request restrictions on the health information we disclose about you and/or your child to a family member, friend or other person who is involved in your and/or your child’s care or the payment for your and/or your child’s care. We are not required to agree to your requested restriction (except that if you are competent you may restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you and/or your child emergency treatment. Access to Personal Health Information. You have the right to inspect and obtain a copy of your and/or your child’s clinical or billing records or other written information that may be used to make decisions about your and/or your child’s care, subject to some exceptions. Your request must be made in writing. In most cases we may charge a reasonable fee for our costs in copying and mailing your requested information. We may deny your request to inspect or receive copies in certain circumstances. If you are denied access to health information, in some cases you have a right to request review of the denial. This review would be performed by a licensed health care professional designated by the Provider who did not participate in the decision to deny. Request Amendment. You have the right to request amendment of your and/or your child’s health information maintained by the Provider for as long as the information is kept by or for the Provider. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information (a) was not created by the Provider, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for the Provider; (c) is not part of the information to which you and/or your child have a right of access; or (d) is already accurate and complete, as determined by the Provider. 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. Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your and/or your child’s health information. This is a listing of disclosures made by the Provider or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosure made pursuant to your Authorization, and certain other exceptions. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs. Request 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. [In addition, you may obtain a copy of this Notice at our website, www.childrenshome-ct.org] Request Confidential Communications. You have the right to request that we communicate with you concerning your and/or your child’s health matters in a certain manner. We will accommodate your reasonable requests. V. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. Except as provided below and as specifically permitted or required under state or federal law, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization. • Psychiatric information. If needed for your and/or your child’s diagnosis or treatment in a mental health program, psychiatric information may be disclosed. Certain limited information may be disclosed for payment purposes. • HIV-related information. HIV-related information may be disclosed for purposes of treatment or payment. • Substance abuse treatment. If you and/or your child are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies. VI. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT If you have any questions about this Notice or would like further information concerning your privacy rights, please contact The Children’s Home Privacy Officer at 60 Hicksville Road, Cromwell, CT 06416, or at (860) 635-6010 . If you believe that your privacy rights have been violated, you may file a complaint in writing with the Provider or with the Office of Civil Rights in the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint. To file a complaint with the Provider, contact The Children’s Home Privacy Officer at 60 Hicksville Road, Cromwell, CT 06416, or at (860) 635-6010 . VII. CHANGES TO THIS NOTICE We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by the Provider as well as for all health information we receive in the future. We will provide a copy of the revised Notice upon request.