Form Name: 802.a Notice of Privacy
HUMAN SERVICE AGENCY
NOTICE OF PRIVACY PRACTICES
4/01/03
I. 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.
II. Our Duty to Safeguard Your Protected Health Information.
Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information: (“PHI”). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.
We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so we will post a new Notice at the receptionist’s window. You may request a copy of the new notice from Receptionist, and it will also be posted on our website at www.humanserviceagency.org.
III. How We May Use and Disclose Your Protected Health Information.
We use and disclose PHI for a variety of reasons. We have a limited right to use and/or disclose your PHI for purposes of treatment, payment or our health care operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following offers more description and some examples of our potential uses/disclosures of your PHI.
Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Generally, we may use or disclose your PHI as follows:
For Treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment, for consultation purposes and/or community mental health agencies involved in provision or coordination of your care.
To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may contact your employer to verify employment status, and/or release portions of your PHI to the Medicaid program, the DHS central office, and/or a private insurer to get paid for services that we delivered to you.
For health care operations: We may use/disclose your PHI in the course of operating our Human Service Agency. For example, we may take your photograph for medication identification purposes, use your PHI in evaluating the quality of services provided, or disclose your PHI to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in our central office or our Office of Support Services for similar purposes. Release of your PHI to state agencies might also be necessary to determine your eligibility for publicly funded services.
Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders and other similar materials to your home.
Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorization can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken and action in reliance upon your authorization.
Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent or Authorizations: The law provides that we may use/disclose your PHI from mental health records without your consent or authorization in the following circumstances.
When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
For Public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority.
For health oversight activities: We may disclose PHI to our central office, the protection and advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.
Relating to decedents: We may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
For research purposes: In certain circumstances, and under supervision of a privacy board, we may disclose PHI to our central office research staff and their designees in order to assist medical/psychiatric research.
To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reason, such as protection of the President.
Uses and Disclosures of PHI from Alcohol and Other Drug Records not Requiring (Consent or) Authorization: The law provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances:
When required by law: We may disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to court order.
Relating to decedents: We may disclose PHI relating to an individual’s death if state or federal law requires the information for collection of vital statistics or inquiry into cause of death.
For research, audit or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit or evaluation purposes.
To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI to law enforcement when a threat is made to commit a crime on the program premises or against program personnel.
Uses and Disclosures Requiring You to have an Opportunity to Object: In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law. However, if there is an emergency situation and you cannot be given an opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.
To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for you care. We may also share PHI with these people to notify them about your location, general condition or death.
IV. Your Rights Regarding Your Protected Health Information. You have the following rights relating to your protected health information:
To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
To choose how we contact you: You have the right to ask that we send your information at an alternative address or by and alternative means. We must agree to your request as long as it is reasonably easy for us to do so.
To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.
To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (i) correct and complete; (ii) not created by us and/or not part of our records, or; (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI.
To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure: for treatment, payment and operations; to you, your family, or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.
To receive this notice: You have the right to receive a paper copy of this Notice and/or electronic copy by email upon request.
V. Questions and Complaints:
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.
We support your right to privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.
VI. Contact Person for Information, or to Submit a Complaint:
If you have questions about this Notice or any complaints about our privacy practices, please contact:
Human Service Agency
Privacy Officer
123 19th Street NE
Watertown, South Dakota 57201
Telephone (605)-886-0123 or (800)-444-3989
VII. Effective Date: This Notice was effective 4/14/03
ASform#100-0
