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Notice of Privacy Practices
Each time the consumer visits a hospital, a physician, or another health care provider, the provider makes a record of the consumer's visit. Typically, this record contains the consumer's heath history, current symptoms, examination and test results, and diagnoses, treatment, and plan for future care, or treatment. This information, often referred to as the Consumer's medical record, serves as the following:
- Basis for planning the consumer's care and treatment.
- Means of communication among the many health professionals who contribute to the consumer's care.
- Legal document describing the care that you received.
- Means by which the consumer or a third-party payer can verify that the consumer actually received the service billed for.
- Tool in medical education
- Source of information for public health officials charged with improving the health of the regions they serve.
- Tool to assess the appropriateness and quality of care that the consumer received.
- Tool to improve the quality of health care and achieve better consumer outcomes. Understanding what is in the consumer's health records and how the consumer's health information is used helps the consumer to-
- Ensure its accuracy and completeness.
- Understand who, what, where, why, and how others may access the consumer's health information.
- Make informed decisions about authorizing rights detailed below.
The Consumer's Rights under the Federal Privacy Standard
Although the consumer's health records are physically property of the health care provider who completed it, the consumer has the following rights with regard to the information contained therein:
- Request restriction on uses and disclosures of the consumer's health information for treatment, payment, and health care operations. "Health care operations" consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under the following sections on the federal privacy regulation: § 164.502 (a) (2) (i) (disclosures to the Consumer), 164.510(a) (for facility directories, but note the consumer has the right to object to such uses), or 1164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory communicable disease reporting. In those cases, the consumer does not have a right to request restriction. The consent to use and disclose the consumer's individually identifiable health information Release of Information form provides the ability to request restriction. Family Service and Guidance Center, Inc. does not, however, have to agree to the restriction. If Family Service and Guidance Center, Inc. does, we will adhere to it unless the consumer requests otherwise or we will give the advance notice. The consumer may also ask us to communicate with the consumer by alternate means, and if the method of communication is reasonable, Family Service and Guidance Center, Inc. must grant the alternate communication request. The consumer may request restriction or alternate communications on the authorization form for treatment, payment, and health care operations.
- Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our website, the consumer has a right to a hard copy upon request.
- Inspect and copy the consumer's health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, Family Service and Guidance Center, Inc. can deny access. The consumer does not have a right of access to the following:
- Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated from the rest of the consumer's medical record.
- Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
- Protected health information ("PHI") that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C. § 263a, to the extent that giving the access would be prohibited by law.
- Information that was obtained from someone other than a mental health care provider under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.
In other situations, Family Service and Guidance Center, Inc. may deny the consumer access, but if we do, we must provide the consumer a review of our decision denying access. These "reviewable" grounds for denial include the following:
- A licensed mental health care professional, such as your therapist/psychiatrist, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of the consumer or another person.
- PHI makes reference to another person (other than a mental health care provider) and a licensed mental health care provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to the consumer or another person.
- The request is made by the consumer's personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that giving access to such personal representative is reasonably likely to cause substantial harm to the consumer or another person.
For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny the consumer access, Family Service and Guidance Center, Inc. will explain why and what the consumer's rights are, including how to seek review. If we grant access, we will tell the consumer what, if anyth
ing, the consumer has to do to get access. Family Service and Guidance Center, Inc. reserves the right to charge a reasonable, cost-based fee for making copies.
- Request amendment/correction of the consumer's health information. We do not have to grant the request if the following conditions exist:
- Family Service and Guidance Center, Inc. did not create the record. If as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, the consumer must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.
- The records are not available to the consumer as discussed immediately above.
- The record is accurate and complete.
If we deny the consumer's request for amendment/correction, Family Service and Guidance Center, Inc. will notify the consumer why, how he/she can attach a statement of disagreement to the consumer's records (which we may rebut), and how the consumer can complain, following the complaint procedure as outlined in the Client Information Packet. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom the consumer identifies to us that the consumer wants to receive the corrected information.
- Obtain an accounting of nonroutine uses and disclosures, those other than treatment, payment, and health care operations. We must provide the accounting within 60 days. The accounting must include the following information:
- Date of each disclosure.
- Name and address of the organization or person who received the protected health information.
- Brief description of the information disclosed.
- Brief statement of the purpose of the purpose of the disclosure that reasonably informs the consumer of the basis for the disclosure or, in lieu of such a statement, a copy of the consumer's written authorization or a copy of the written request for disclosure.
- We do not need to provide an accounting for the following disclosures:
- To the consumer for disclosures of protected health information to the consumer.
- For uses and disclosures that the consumer authorized.
- For the facility directory or to persons involved in the consumer's care or for other notification purposes as provided in §164.510 of the federal privacy regulations (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for the consumer's care, of the consumer's location, general condition, or death)
- For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
- To correctional institutions or law enforcement officials under § 164.512 (k)(5) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
- That occurred before April 14,2003.
The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.
- Revoke the consumer's consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.
Our Responsibilities under the Federal Privacy Standard
In addition to providing the consumer his/her rights, as detailed above, the federal privacy standard requires us to take the following measures:
- Maintain the privacy of the consumer's health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
- Obtain appropriate documentation (BAC) with entities that either perform certain services "for" Family Service and Guidance Center Inc., or acts "on behalf" of Family Service and Guidance Center, Inc. to ensure these entities follow our policies and procedures to protect our consumer Health Information.
- Provide the consumer this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about him/her.
- Abide by the terms of this notice.
- Train our personnel concerning privacy and confidentiality. Access of consumer Health Information will be granted on a "need to know" basis according to specific job responsibilities. Any modifications to access of consumer Health Information must be evaluated / approved by the Privacy and / or Security Officer. Access to consumer Health Information will be reviewed on an annual basis.
- Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies or our policies with regard thereto.
- Mitigate (lessen the harm of) any breach of privacy/confidentiality. Family Service and Guidance Center, Inc. will not use or disclose the consumer's health information without the consumer's consent or authorization, except as described in this notice or otherwise required by law.
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