NOTICE 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.

 

It is important to read and understand this Notice of Privacy Practices before signing the Consent and Acknowledgment Form.

Notice of Privacy Practices
Effective Date: September 23, 2013

PURPOSE OF 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 and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use of share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

 

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. This notice applies to the following organization and its locations: Community Health Services, Inc. at 500 Albany Avenue, Hartford, CT 06120 and Community Health Services, Inc. at 503 Windsor Avenue, Windsor, CT 06095

HOW MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

CHS will ask you to sign a consent form that allows CHS 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 on the Consent and Acknowledgement Form.

 

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, CHS 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 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. We may disclose this information about you to doctors, dentists, nurses, technicians, students, or other Health Center personnel who are involved in taking care of you. Your protected health information may be used, for example, to communicate with the Department of Children and Families, a school, or a primary care physician to coordinate treatment. 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 CHS and for other treatment reasons. We may also use or disclose your protected health information in an emergency situation. If we are permitted to do so, we may also disclose or allow electronic access to your protected health information to a health care provider you designate for follow-up care, care coordination, and for other treatment purposes.
     

  • 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 the insurance company information about the treatment you received so your insurance company will pay us or reimburse us for the treatment, or we may contact your insurance company 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 CHS, 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 CHS For example, CHS will use or disclose protected health information during licensing and accrediting site visits.
     

  • Appointment Reminders – We may use and disclose protected health information to contact you as a reminder that you have an appointment at CHS
     

  • 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.
     

  • Business Associates – There may be some services provided by our business associates, such as software maintenance for electronic health records, 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.
     

  • 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 or deaths, 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.
     

  • Research Purposes – Your protected health information may be used for research purposes, but only if the privacy aspects of the research have been reviewed and approved by CHS, or if you provide authorization.
     

  • Comply with Law – We may disclose your protected health information to a state or federal oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure.
     

  • Respond to Organ and Tissue Donation Requests – We can share health information about you to organ procurement organizations.
     

  • Work with medical examiner or funeral director – We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
     

  • Judicial and Administrative Proceedings – If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to 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.
     

  • 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 and safety or the health and 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 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 Mental Health, Substance Abuse, and HIV-Related Information and Information of Minors – For disclosures concerning protected health information relating to care for mental health conditions, substance abuse or HIV related testing and treatment and minors, 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 or social worker 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, your permission will be needed for certain disclosures, but not emergencies, certain reporting requirements and other disclosures specifically allowed under 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.
     

  • HIV related information. We may disclose HIV related information as permitted or required by Connecticut law. For example your HIV-related protected health information, if any, may be disclosed in the event of a significant exposure to HIV-infection to personnel of CHS, another person, or a known partner. Any use and disclosure for such purposes will be to someone able to reduce the outcome of the exposure and limited in accordance with Connecticut and Federal law.
     

  • 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, 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.

YOUR CHOICES
  • Fundraising Activities – We may contact you for fundraising efforts, but you can tell us not to contact you again.
     

  •  In these cases you have both the right and choice to tell us to: share information with your family, close friends, or other involved in your care; share information in a disaster relief situation; and contact you for fundraising efforts.
     

  • In these cases we never share your information unless you give us written permission: Marketing purposes; sale of your information; and most sharing of psychotherapy notes.

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.

  • Get an electronic or paper copy of your medical record – You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
     

  • Ask us to correct your medical record – You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
     

  • Request confidential communications – You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
     

  • Ask us to limit what we use or share – You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
     

  • Get a list of those with whom we’ve shared information -You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
     

  • Get a copy of this privacy notice – You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
     

  • Choose someone to act for you – If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
     

  • File a complaint if you feel your rights are violated – You can complain if you feel we have violated your rights by contacting us as below:

Privacy Officer

Community Health Services, Inc.

500 Albany Avenue

Hartford, CT 06120

860-249-9625

 

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.