NOTICE OF PRIVACY INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW
MEDICAL AND DRUG & ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
A.
PURPOSE
OF THE NOTICE.
ARA
is committed to preserving the privacy and confidentiality of your health
information. Information about your
treatment and care, including payment for care, is protected by two federal
laws: The Health Insurance Portability
and Accountability Act of 1996 (HIPAA) (42 USC §130d et. Seq., 45 CFR Parts 160
& 164) and the Confidentiality Law (42 USC § 290dd-2, 42 CFR Part 2). State and federal laws and regulations
require us to establish policies and procedures to protect the privacy of your
health information, which includes any information that relates to your past,
present or future health/mental health condition (which might include your
photograph) may be used and released by ARA for the purposes of providing
treatment to you. This Notice will
provide you with information about our privacy practices toward all of your
health information created and/or maintained at this office, including any
information that we receive from other health care providers or
facilities. The Notice describes the
ways in which we may use or disclose (share) your health information and also
describes your rights and our responsibilities concerning such uses or
disclosures.
We will abide by the terms of this Notice,
including any future revisions that we may make to the Notice as required or
authorized by law. We reserve the right
to change this Notice and to make the revised or changed Notice effective for
health information we already have about you as well as any information we receive
in the future. We will post a copy of
the current Notice, which will identify its effective date, in our program
waiting areas.
The privacy practices described in this Notice
apply to:
- Program staff for
the purposes of providing treatment, maintaining the clinical record,
staff supervision, incident reporting, medication administration, billing
operations, and other treatment related processes;
2. Business
Associates such as laboratories (bloodwork, urinalysis), and agencies that
provide on-site delivery services, and;
3. Reporting
to the NYS OASAS Client Data System, only if you are enrolled in our
alcoholism/substance abuse clinic
The individuals identified above may share your
health information with each other for purposes of treatment, payment, and
health care operations, as further described in the Notice.
B.
THE
FOLLOWING ARE USES AND DISCLOSURES OF HEALTH INFORMATION THAT YOU MAY EXPECT ON
A ROUTINE BASIS FROM OUR OFFICE:
1. Treatment. We may use health information about you to
provide you with treatment or services.
Individuals and programs within ARA may share health information about
you to coordinate the services you may need, such as clinical examinations,
medications, hospitalizations or transfers or referrals for follow-up
care.
2. Payment. We may use or disclose your health information
so that we may bill and receive payment from you, an insurance company, or
another third party for the health care services you receive from us.
3. Health Care Operations. We may use or disclose your health
information in order to perform the necessary administrative, educational,
quality assurance, and business functions of our clinic, including but not
limited to requiring you to sign in upon arrival, calling out your name when it
is time for your visit, and discussing aspects of your medical care when
consulting with others regarding your care, next visit or special needs.
C. USES AND DISCLOSURES OF
HEALTH INFORMATION IN SPECIAL SITUATIONS.
We may use or disclose your health information in
certain special situations as described below.
For these situations, you have the right to limit these uses and
disclosures as provided for in this Notice.
- Appointment
Reminders. We may use or disclose your health information for purposes of
contacting you to remind you of a health care appointment. Be aware that
these reminders may be left on your answering machine at your home.
- Family
Members and Friends. We may
disclose your health information to family members and friends, who are
involved in your care or who help pay for your care. We may make such disclosures when: (a) we have your verbal agreement to do
so; (b) we make such disclosures and you do not object; or (c) we can
infer from the circumstances that you would not object to such
disclosures. For example, if your
spouse comes into the therapist’s office with you, we will assume that you
agree to our disclosure of your information while your spouse is present
in the room.
D.
OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH
INFORMATION.
There are certain instances in which we may be
required or permitted by law to use or disclose your health information without
your permission. These instances are as
follows:
- As required
by law. We may
disclose your health information when required by federal, state, or local
law to do so.
- Public Health
Activities. We may disclose your health information to public health
authorities that are authorized by law to receive and collect health
information for the purpose of preventing or controlling disease, injury,
or disability; to report births, deaths, suspected abuse or neglect,
reactions to medications; or to facilitate product recalls.
- Health
Oversight Activities. We may
disclose your health information to a health oversight agency that is
authorized by law to conduct health oversight activities, including
audits, investigations, inspections, or licensure and certification
surveys. These activities are
necessary for the government to monitor the persons or organizations that
provide health care to individuals and to ensure compliance with
applicable state and federal laws and regulations.
- Judicial or
administrative proceedings. We may
disclose your health information to courts or administrative agencies
charged with the authority to hear and resolve lawsuits or disputes. We may disclose your health information
pursuant to a court order, a subpoena, a discovery request, or other
lawful process issued by a judge or other person involved in the dispute,
but only if efforts have been made to (i) notify you of the request for
disclosure or (ii) obtain an order protecting your health information.
- Worker’s
Compensation. We may
disclose your health information to worker’s compensation programs when
your health condition arises out of a work-related illness or injury.
- Law
Enforcement Official. We may
disclose your health information in response to a request received from a
law enforcement official to report criminal activity or to respond to a
subpoena, court order, warrant, summons, or similar process.
- Coroners,
Medical Examiners, or Funeral Directors. We may disclose your health information
to a coroner or medical examiner for the purpose of identifying a deceased
individual or to determine the cause of death. We also may disclose your health
information to a funeral director for the purpose of carrying out his/her
necessary activities. We may provide this information when death is
anticipated, not just after.
- Research. We may use or disclose your health
information for research purposes under certain limited
circumstances. In most instances,
we will ask for your specific permission to use or disclose your health
information if the researcher will have access to your name, address, or
other identifying information.
- To Avert a
Serious Threat to Health or Safety. We may use or disclose your health
information when necessary to prevent a serious threat to the health or
safety of you or other individuals.
- Military and
Veterans. If you
are, or were a member of the armed forces, we may use or disclose your
health information as required by military command authorities or the
Veteran’s Administration.
- National
Security and Intelligence Activities. We may use or disclose your health information
to authorized federal officials for purposes of intelligence,
counterintelligence, and other national security activities, as authorized
by law.
- Disaster
Management. In the event
of a disaster, your health information may be released as necessary to
allow for your treatment, continued management, transferring of
prescriptions or similar activities.
E. USES AND DISCLOSURES REQUIRING
YOUR WRITTEN AUTHORIZATION.
Other uses and disclosures
require your authorization. Disclosure of your health information or its use for any
purpose other than those listed above requires your specific written
authorization. You have the right to revoke a written
authorization at any time as long as you do so in writing. If you revoke your authorization, we will no
longer use or disclose your health information for the purposes identified in
the authorization, except to the extent that we have already taken some action
in reliance upon your authorization.
Note: Revoking consent to
disclose information to a court, probation department, parole office, etc. may
violate an agreement that you have with that organization. Such a violation may result in legal
consequences for you.)
F. YOUR
RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have the following rights regarding your health
information. You may exercise each of
these rights, in writing, by providing us with a completed form that you
can obtain from our front desk. In some instances, we may charge you for the
cost(s) associated with providing you with the requested information. Additional information regarding how to
exercise your rights, and the associated costs, can be obtained from our
practice receptionists.
- Right to
Inspect and Copy. You
have the right to inspect and copy health information that may be used to
make decisions about your care. Usually, this includes medical and billing
records. It does not include
information that is needed for civil, criminal or administrative actions
or proceedings. As permitted by Federal regulations, we
require that requests to inspect or copy protected information be
submitted in writing. We may charge
a fee for the costs of copying, mailing or other supplies associated with
your request.
As permitted by Federal regulations, we require
that requests to inspect or copy protected information be submitted by
completing a form that is available at the reception desk. To inspect or obtain a copy of the health
information that may be used to make decisions about you, you must submit this
form to the program director of the facility where you are receiving
services. We may deny your request to
inspect and copy your health information in certain limited circumstances. If you are denied access to your health
information, you may request that the denial be reviewed. A Medical Records
Access Review Committee will review your request and denial. The person(s) conducting the review will not
include the person who denied your request.
We will notify you of the outcome of the review and comply with the
outcome.
- Right to
Correct. You have the
right to request corrections be made to your health information maintained
by our office.
- Right to
Amend. You
have the right to request an amendment of your health information that is
maintained by our office and is used to make health care decisions about
you. We may deny your request if it
is not properly submitted or does not include a reason to support your
request. We may also deny your
request if the information sought to be amended: (a) was not created by us, unless the
person or entity that created the information is no longer available to
make the amendment; (b) is not part of the information that is kept by or
for our office; (c) is not part of the information which you are permitted
to inspect and copy; or (d) is determined to be accurate and complete.
To request an amendment,
your must complete the appropriate form and submit it to the Director of the
program in which you are enrolled. In
addition, you must provide a reason that supports your request.
- Right to an
Accounting of Disclosures. You
have the right to request an accounting of the non-routine disclosures of
your health information made by us.
This accounting will not include disclosures of health information
that we made for (1) purposes of treatment, payment or health care operations; (2)
made for national security; (3)
made to correctional and other law enforcement custodial situations; (4)
made based on your written authorization; (5) made to person
involved in your care; or, (6) made prior to April 14, 2003.
To request this list, or
an accounting of disclosures, you must submit your request in writing to the
Director of the program in which you are enrolled for treatment. Your request must state a time period which
may not be longer than 6 years and may not include dates before
- Right to
Request Restrictions. You
have the right to request a restriction or limitation on the health
information we use or disclose about you for treatment, payment, or health
care operations. You also have the
right to request a limit on the health information we disclose about you
to someone, such as a family member or friend, who is involved in your
care or in the payment of your care.
For example, you could ask that we not use or disclose information regarding
a particular treatment that you received.
We are not required to agree to your request. If we do agree, that agreement must be
in writing and signed by you and us.
To request restrictions,
you must make your request in writing to the Director of the program in which
you are enrolled for treatment. Your
request should detail (1) what information you want to limit; (2) whether you want to limit our use,
disclosure or both and; (3) to whom you want the limits to apply (for example,
disclosures to your spouse)
- Right to
Request Confidential Communications. You have the right to
request that we communicate with you about your health care in a certain
way or at a certain location. For
example, you can ask that we only contact you at work or by mail.
To request confidential
communications, you must make your request in writing, to your assigned
therapist. Your request should describe
how and/or where you wish to be contacted. We will not ask you the reason for this
request and we will make every reasonable accommodation to honor your
request.
- Right to a
Paper Copy of this Notice. You
have the right to receive a paper copy of this Notice. You may ask us to give you a copy of
this Notice at any time. ARA
reserves the right to modify the privacy practices outlined in this notice
at any time.
G. QUESTIONS
OR COMPLAINTS.
If you believe your
privacy rights have been violated, you may file a complaint with our Administrative
offices or any of the following governmental agencies. To file a complaint you
can do so by sending a letter outlining your concerns to:
To file a complaint
with the ARA Administrative offices, contact:
ARA
Or,
Secretary
of Health and Human Services
Or,
Office
for Civil Rights
US
Department of Health and Human Services
26
Federal Plaza,
Voice
Phone: (212) 264-3313
FAX: (212) 264-3039
TDD: (212) 264-2355
OCR
Hotlines – (Voice Phone) 1-800-368-1019
You will not be penalized for filing a complaint.
Effective date of this privacy notice is
Acknowledgment of Receipt of Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices for
ARA.
Name of Client
(Print or Type)
___________________________________________________________ ________________________
Signature of Client Date
___________________________________________________________ ________________________
Signature of Client Representative Date
(Required if the client is a minor
or an adult who is unable to sign this form.)
___________________________________________________________
Relationship of Client
Representative to Client
Attempt to Obtain Acknowledgment
An attempt was made to obtain an acknowledgment of receipt of
the Notice of Privacy Practices on __________.
The acknowledgment was not obtained because: (Date)
[ ] The client was undergoing emergency
treatment [ ]
The client declined to sign the acknowledgement
[ ] Other
________________________________________________
___________________________________________________________
Name of Client (Print or Type)
___________________________________________________________
Name of Staff Member
___________________________________________________________
Date
Information
Release Authorization
May we leave a message about your care
or appointment(s) on your answering machine or voice mail OR on the answering
machine or voice mail of your approved contacts?
1 Yes 1 No _______ (Initials)
Please indicate who may be given
information about your care or condition:
1 Spouse 1 Specific
Children: Please
Specify:_______________________________________
1 All Children 1 Other Family: Please
Specify:__________________________________________
1 Other:
Please Specify:__________________________________________________________________