Family Service Privacy Notice

Effective Date:  April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Family Service, Inc. (FSI) has a duty to safeguard your protected health information.  FSI will protect the privacy of the health information during the provision of counseling or payment for your care.  FSI is required by federal law to provide you with this Notice that explains how, when and why FSI may use and disclose your health information.  With some exceptions, FSI will always try to use or disclose the least amount of your health information as is necessary to accomplish a purpose.  Federal law and regulation requires FSI to follow the privacy practices that are described in this Notice.

FSI reserves the right to change the terms of this Notice and our privacy practices at any time.  Changes will apply to any of your health information that we already have.  Before we make a change to our policies, we will change this Notice and post an updated Notice in the reception area.  You may also request, at any time, a copy of our current Privacy Notice from the receptionist. You may also view and obtain an electronic copy of this Notice on our web site at www.FamilyServiceInc.com.

QUESTION:  HOW WILL FSI USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION?

Answer:  FSI uses and discloses health information for different reasons.  For some of these uses or disclosures, we need your specific permission.  Below, we describe the different categories of our uses and disclosures, with examples.

A.            Uses and Disclosures Relating to Treatment, Payment, or Healthcare Operations.  According to federal law FSI may use and disclose your health information for the following reasons:

1.             To Obtain Payment for counseling:  For example, FSI may provide certain portions of your health information to your health insurance company to receive payment for your care.  With the possible exception of information concerning drug and alcohol abuse and/or treatment, and HIV status (for which we may need your specific authorization.) See attached “Payment for Service” for a detailed explanation of payment information.

2.             For Treatment: We may disclose your health information to other health care providers who are involved in your care. For example, your counselor may discuss your situation with the FSI psychiatrist to evaluate if medication may be helpful. 

3.             For Health Care Operations:  We may, at times, need to use and disclose your health information to run our organization.  For example, we may use your health information to evaluate the quality of the treatment that our staff has provided to you.  We may also need to provide some of your health information to our accountants, attorneys, and consultants to make sure that we are complying with the law.  Because this information concerns mental health disorders, drug/alcohol abuse and treatment, or HIV status, FSI may be further limited in what we provide and may be required to first obtain your authorization.

4.             Other:         FSI will try to have no individually identifiable health information visible so that a person walking through our offices may see the information.

B.            Certain Other Uses and Disclosures are Permitted by Federal Law.  We may use and disclose your health information without your authorization for the following reasons:

1.             When a Disclosure is Required by Federal, State, or Local Law, in Judicial or Administrative Proceedings, or by Law Enforcement.  For example, we may disclose your protected health information if a court orders us, or if a law requires that we report information to a government agency or law enforcement authorities. Examples of such disclosure requirements are suspected child, elder, disabled person abuse.  See attached “Facts about Professional Confidentiality” for a detailed explanation of exceptions.

2.             For Public Health Activities.  Under the law, we need to report information about certain diseases and about any deaths to government agencies that collect that information.  With the possible exception of information concerning HIV status (for which we may need your specific authorization), we are also permitted to provide some health information to the coroner or a funeral director, if necessary, after a client's death.

3.             For Health Oversight Activities.  We may need to provide your health information to the State when they oversee the program in which you receive care.  We will also need to provide information to government agencies that have the right to inspect our offices and/or investigate healthcare practices.

4.             For Research Purposes.  In certain limited circumstances (for example, where approved by an appropriate Privacy Board or Institutional Review Board under federal law), we may be permitted to use or provide protected health information for a research study.

5.             To Avoid Harm.  If one of our staff members believes that it is necessary to protect you, or to protect another person or the public as a whole, we may provide protected health information to the police or others who may be able to prevent or lessen the possible harm.

6.             For Specific Government Functions.  Similarly, with the possible exception of information concerning drug and alcohol abuse and/or treatment, and HIV status (for which we may need your specific authorization), we may also disclose a client's health information for national security purposes. We may disclose the health information of military personnel or veterans where required by U.S. military authorities

7.             For Workers' Compensation.  We may provide your health information as described under the workers' compensation law, if your condition was the result of a workplace injury for which you are seeking worker's compensation.

8.             Appointment Reminders and Health-Related Benefits or Services.  Unless you tell us that you would prefer not to receive them, we may use or disclose your information to provide you with appointment reminders or alternative programs and treatments that may help you.

9.             Fundraising Activities.  For example, if FSI chose to raise funds to support one or more of our programs or facilities, or some other charitable cause or community health education program, we may use the information that we have about you to contact you.  If you do not wish to be contacted as part of any fundraising activities, please inform your counselor or the Privacy Officer.

C.            Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1.             Disclosures to Family, Friends, or Others Involved in Your Care.  We may provide a limited amount of your health information to a family member, friends, or other person known to be involved in your care or in the payment for your care, unless you tell us not to.  For example, if a family member comes with you to your appointment and you allow them to come into the counselor’s office with you, we may disclose otherwise protected health information to them during the appointment, unless you tell us not to.

2.             Disclosures to Notify a Family Member, Friend, or Other Selected Person.  When you first come to FSI, we ask that you provide us with an emergency contact person in case something should happen to you while you are at our facilities.  Unless you tell us otherwise, we will disclose limited health information about you (your general condition, location, etc.) to your emergency contact or another available family member.  (For example, should you need to be admitted to the hospital).

D.            Other Uses and Disclosures Require Your Prior Written Authorization.  In situations other than those categories of uses and disclosures mentioned above, or those disclosures permitted under federal law, we will ask for your written authorization before using or disclosing any of your protected health information.

If you choose to sign an authorization to disclose any of your health information, you can later revoke it to stop further uses and disclosures to the extent that we haven't already taken action relying on the authorization, so long as it is revoked in writing.

QUESTION:  WHAT RIGHTS DO I HAVE CONCERNING MY PROTECTED HEALTH INFORMATION?

Answer:  You have the following rights with respect to your protected health information:

A.            The Right to Request Limits on Uses and Disclosures of Your Health Information.  You have the right to ask us to limit how we use and disclose your health information.  We will certainly consider your request, but you should know that we are not required to agree to it.  If we do agree to your request, we will put the limits in writing and will abide by them, except in the case of an emergency.  Please note that you are not permitted to limit the uses and disclosures that we are required or allowed by law to make.

B.            The Right to Choose How We Send Health Information to You or How We Contact You.  You have the right to ask that we contact you at an alternate address or telephone number (for example, sending information to your work address instead of your home address) or by alternate means.  We must agree to your request so long as we can easily do so.

C.            The Right to See or to Get a Copy of Your Protected Health Information.  In most cases, you have the right to look at or get a copy of your health information that we have, but you must make the request in writing. We will respond to you within 30 days after receiving your written request.  If we do not have the health information that you are requesting, but we know who does, we will tell you how to get it.  In certain situations, we may deny your request.  If we do, we will tell you, in writing, our reasons for the denial.  In certain circumstances, you may have a right to appeal the decision.

If you request a copy of any portion of your protected health information, the charges are $5 for the first page and $.50 per subsequent single sided page.  We need to require that payment be made in full before we will provide the copy to you.  If you agree in advance, we may be able to provide you with a summary or an explanation of your records instead.  There will be a charge for the preparation of the summary or explanation, including charge for staff time to develop the summary.

D.            The Right to Receive a List of Certain Disclosures of Your Health Information That We Have Made.  You have the right to get a list of certain types of disclosures that we have made of your health information.  This list would not include uses or disclosures for treatment, payment or healthcare operations, disclosures to you or with your written authorization, or disclosures to your family for notification purposes or due to their involvement in your care.  This list also would not include any disclosures made for national security purposes, disclosures to corrections or law enforcement authorities if you were in custody at the time, or disclosures made prior to April 14, 2003.  You may not request an accounting for more than a six (6) year period.

To make such a request, we require that you do so in writing; a request form is available from your counselor.  We will respond to you within 60 days of receiving your request.  The list that you may receive will include the date of the disclosure, the person or organization that received the information (with their address, if available), a brief description of the information disclosed, and a brief reason for the disclosure.  We will provide such a list to you at no charge; but, if you make more than one request in the same calendar year, you will be charged $10 for each additional request that year.

E.             The Right to Ask to Correct or Update Your Health Information.  If you believe that there is a mistake in your health information or that a piece of important information is missing, you have a right to ask that we make an appropriate change to your health information.  You must make the request in writing with the reason for your request.  We will respond within 60 days of receiving your request.  If we approve your request, we will make the change to your health information, tell you when we have done so, and will tell others that need to know about the change.

We may deny your request if the protected health information: (1) is correct and complete; (2) was not created by us; (3) is not allowed to be disclosed to you; or (4) is not part of our records.  Our written denial will state the reasons that your request was denied and explain your right to file a written statement of disagreement with the denial.  If you do not wish to file a written statement of disagreement, you may ask that we include a copy of your request, and our denial, with all future disclosures of that health information.

QUESTION:  HOW DO I COMPLAIN OR ASK QUESTIONS ABOUT THIS ORGANIZATION'S PRIVACY PRACTICES?

Answer:  If you have any questions about anything discussed in this Notice or about any of our privacy practices, or if you have any concerns or complaints, discuss them with your counselor.  You can also contact FSI’s Privacy Officer, the Assistant Executive Director.  You also have the right to file a written complaint with the Secretary of the U.S. Department of Health and Human Services. See attached “Client Complaint Procedure.” We cannot take any retaliatory action against you if you lodge any type of complaint.

Family Service Privacy Notice