WEST HAVEN COMMUNITY HOUSE ASSOCIATION, INC.
227 ELM STREET, WEST HAVEN, CT 06516 TELEPHONE: 934-5221 FAX: 937-9052
www.whcommunityhouse.org [email protected]
Established in 1941, the West Haven Community House exists to facilitate healthy, productive, independent
and meaningful lives for children, adolescents and families, and individuals with disabilities.
THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
IMPORTANT
NOTICE OF PRIVACY PRACTICES
WEST HAVEN COMMUNITY HOUSE
It is important to read and understand this Notice of Privacy Practices before signing the Consent
and Acknowledgement Form.
If you have any questions about the Notice or would like further information concerning your privacy
rights, please contact the West Haven Community House Privacy Officer.
WEST HAVEN COMMUNITY HOUSE
WHCH Privacy Officer
227 Elm Street
West Haven, CT 06516
(203) 934-5221

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Notice of Privacy Practices
Effective Date: September 23, 2013
Purpose of the 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.
What is 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.
Common identifiers of health information include names, social security numbers,
addresses and birthdates.
We are required by law to maintain the privacy of your protected health information. We are also
required by law to provide you with this Notice of our legal duties and privacy practices with respect
to your protected health information and abide by the terms of the Notice that is currently in effect.
However, we may change our notice at any time. The new revised Notice will apply to all of your
protected health information maintained by us. You will not automatically receive a revised Notice. If
you would like to receive a copy of any revised Notice you should contact the WEST HAVEN
COMMUNITY HOUSE (“WHCH”).
How We May Use of Disclose Your Protected Health Information
WHCH will ask you to sign a consent form that allows WHCH to use and disclose your protected
health information for treatment, payment and health operations. You will also be asked to
acknowledge receipt of this Notice.
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, WHCH may use and disclose your
protected health information as permitted by 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 needs access to carry out their duties. In addition, if
required, 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 use or disclosure is limited by law.
I. USES AND DISCLOSUES FOR TREATMENT, PAYMENT AND HEALTH CARE
OPERATIONS
By your participation in a program of the West Haven Community House, information about you
must be used and disclosed to other parties for purposes of treatment, payment, and health care
operations. These uses and disclosures do not require your consent:
For Treatment. We may use and disclose your health information in providing you with medical
treatment and related services and coordinating your care and may disclose information to other
providers involved in your care. If we are permitted to do so, we may also disclose your protected

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health information to individuals or facilities that will be involved with your care after you leave
WHCH and for other treatment reasons. We may also use or disclose your protected health
information in an emergency situation.
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 representative, or to an insurance or
managed care company, Medicare, Medicaid or another third-party payer. For example, we may
need to give your child care assistance program, Medicare or your health plan to confirm your
coverage or to request approval for services that will be provided to you.
For Health Care Operations. We may use or disclose your health information as necessary for
operations of WHCH, 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 WHCH.
II. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
The following lists various ways in which we may use or disclose your health information for which
you are consenting or as required by law or as allowed by HIPAA.
Individuals Involved in Your Care or Payment of Your Care. With your consent, we may
disclose health information about you to a family member, close personal friend or other person you
identify, including clergy, who is involved in your care.
Emergencies. We may use or disclose your health information as necessary in emergency
treatment situations.
As Required By Law. We may use or disclose your health information when required by law to
do so.
Business Associate. We may disclose your personal health information to a contractor or
business associate that needs the information to perform services for West Haven Community
House. To protect your health information, we have our business associates sign written contracts
that require them to keep your information confidential. For example, our computer consultant may
have access to certain personal health information, but is required by law and our contract with
them to keep the information confidential and not use it.
Public Health Activities. We may disclose your health information for public health activities.
These activities may include, for example, reporting to a public health authority for preventing or
controlling disease, injury or disability; reporting to the Federal Food and Drug Administration issues
concerning problems with products or product recalls, or reporting births and deaths.
Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a
victim of abuse, neglect or domestic violence, we may use or disclose your health information to
notify a government authority, if authorized by law, or if you agree to the report.

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Health Oversight Activities. We may disclose your health information to a health oversight
committee for activities authorized by law, such as audits, investigations, inspections and licensure
actions or for activities involving government oversight of the health care system.
To Avert a Serious Threat to Health or Safety. We may use or disclose health information to
prevent a serious threat to your health or safety or the health or safety of others limiting disclosures
to someone able to help lessen or prevent the threatened harm.
Judicial and Administrative Proceedings. We may disclose your health information in response
to a court or administrative order. We also may disclose information in response to a subpoena,
discovery request, or other lawful process if we are authorized to do so under the law. [When we
receive a court order, subpoena, discovery request or other lawful process, we will attempt
to contact you about the request and to protect your treatment information to the extent
provided by law until such time as we receive your consent to disclose the treatment
information or a court order.]
Law Enforcement. We may disclose your health information for certain law enforcement purposes,
including, for example, complying with reporting requirements; to comply with a court order, warrant,
or similar legal process; or to answer certain requests for information concerning crimes.
Research. We may use or disclose your health information for research purposes if the privacy
aspects of the research have been reviewed and approved, if the researcher is collecting
information in preparing a research proposal, if the research occurs after your death, or if you
authorize the use or disclosure.
Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We
may release your health information to a coroner, medical examiner, funeral director or, if you are
an organ donor, to an organization involved in the donation of organs and tissue.
Disaster Relief. We may disclose health information about you to a disaster relief organization.
Military, Veterans and other Specific Government Functions. If you are a member of the armed
forces, we may use and disclose your health information as required by military command
authorities or for the purpose of determining your eligibility for benefits by the Department of
Veterans Affairs. We may disclose health information for national security purposes or as needed to
protect the President of the United States or certain other officials or to conduct certain special
investigations.
Workers’ Compensation. We may use or disclose your protected health information as permitted
by laws relating to workers’ compensation or related programs.
Benefit Programs. We may use or disclose your health information to comply with laws and
obligations relating to workers’ compensation or other similar State or Federal benefit programs.
Inmates/Law Enforcement Custody. If you are under the custody of a law enforcement official or
a correctional institution, we may, if authorized by law, disclose your health information to the
institution or official for certain purposes including the health and safety of you and others.

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Fundraising Activities. If authorized by law, we may use certain limited information to contact you
in an effort to raise funds for the West Haven Community House and its operations. However, you
may opt-out from receiving such communications.
Treatment Alternatives and Health-Related Benefits and Services. With your consent, we may
use or disclose your health information to inform you about treatment alternatives and health-related
benefits and services that may be of interest to you and that are offered by WHCH or its affiliates.
Appointment Reminders. We may use and disclose protected health information to contact you as
a reminder that you have an appointment at WHCH.
III. USES AND DISCLOSURES WITH YOUR AUTHORIZATION
THE WEST HAVEN COMMUNITY HOUSE WILL NOT BE SELLING YOUR PERSONAL HEALTH
INFORMATION AT ANY TIME. Uses and disclosures not described in this Notice will be made
ONLY with your Authorization. You may revoke an Authorization in writing at any time. If you
revoke an Authorization, we will no longer use or disclose your health information for the purposes
covered by that Authorization, except where we have already relied on the Authorization.
IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Listed below are your rights regarding your health information. Each of these rights is subject to
certain requirements, limitations and exceptions. Exercise of these rights may require submitting a
written request to WHCH by you. At your request, WHCH will supply you with the appropriate form
to complete, if you wish.
Right to Request Restrictions. You have the right to request restrictions on our use or disclosure
of your health information for treatment, payment or health care operations. You also have the right
to request restrictions on the health information we disclose about you to a family member, friend or
other person who is involved in your care or the payment for your care.
We are not required to agree to your requested restriction (except if you restrict disclosures to family
members or friends other than a conservator or listed health care agent). If we do agree to accept
your requested restriction, we will comply with your request except as needed to provide you
emergency treatment or in accordance with applicable law. However, you have the right to restrict
certain disclosures of personal health information to a health insurance payer where the disclosure
is for payment or health care operations and pertains to a health care item or service for which you
(or any person other than the health insurance payer) have paid for the treatment in full.
Right to Access to Personal Health Information. You have the right to request copies of your
personal health information in any form you choose, provided that the personal health information is
readily producible in that format. You have the right to request your personal health information
electronically or have it directly transmitted to a third party specified by you per our capabilities.
Your request must be made in writing. In most cases we may charge a reasonable, cost-based fee
for preparing the copy, which will not exceed our labor costs in responding to your request and
postage, if applicable.

WEST HAVEN COMMUNITY HOUSE ASSOCIATION, INC.
227 ELM STREET, WEST HAVEN, CT 06516 TELEPHONE: 934-5221 FAX: 937-9052
www.whcommunityhouse.org [email protected]
Established in 1941, the West Haven Community House exists to facilitate healthy, productive, independent
and meaningful lives for children, adolescents and families, and individuals with disabilities.
WEST HAVEN COMMUNITY HOUSE PRIVACY PROTECTION POLICY
For Social Security Numbers
The West Haven Community House collects certain personal information, including Social Security
numbers, in the course of our business. We will make what we believe to be reasonable efforts to protect
the confidentiality of the Social Security numbers that we collect.
We protect the confidentiality of the Social Security numbers we collect in the course of business by
maintaining physical, electronic and procedural safeguards to protect their confidentiality, including:
 Limiting access to the Social Security numbers we collect
 Prohibiting unlawful disclosure of the Social Security numbers we collect
 Requiring that third parties with access to Social Security numbers protect their confidentiality
 Keeping Social Security numbers locked in the HR Administrator’s office in a locked file cabinet
 Requiring signed documentation from employee regarding access to confidential Social Security
number by unauthorized individuals
The following is a list of confidential information which is contained in personnel files:
 Social Security Numbers
 Drivers License/State Identification Numbers
 Bank Account Numbers for Direct Deposit
 Passport Numbers included on I-9 Form
 Alien Resident Number included on I-9 Form
DESTRUCTION OF CONFIDENTIAL INFORMATION
All Personnel files are kept for a period of seven years after the employee has left the agency. At the
beginning of the eighth year, terminated employees are updated on our Termination List and their file is
shredded.
If a new computer is purchased for payroll the hard drive of the old computer is immediately destroyed.
SECURITY BREACH PROCEDURES
In the event of a security breach, the West Haven Community House will contact all employees who may
be affected via written letter, email or substitute notification (web page) as soon as possible after it has
been determined that a breach has occurred. Notification may be delayed if a criminal investigation is
warranted and law enforcement requests the delay.