WEST HAVEN COMMUNITY HOUSE ASSOCIATION, INC. 227 ELM STREET, WEST HAVEN, CT 06516TELEPHONE: 934-5221FAX: 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
Page 2 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
Page 3 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.
Page 4 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.
Page 5 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.
Page 6 We may deny your request to inspect or receive copies in certain circumstances. If you are denied access to health information, in some cases you have a right to request review of the denial. This review would be performed by a licensed health care professional designated by WHCH who did not participate in the decision to deny. Right to Request Amendment.You have the right to request amendment of your health information maintained by WHCH for as long as the information is kept by or for WHCH. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information (a) was not created by WHCH, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for WHCH; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by WHCH. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial. Right to Request an Accounting of Disclosures.You have the right to request an “accounting” of certain disclosures of your health information. This is a listing of disclosures made by WHCH or by others on our behalf.This includes disclosures made for treatment, payment and health care operations if the disclosures are made through an electronic health record. To request an accounting of disclosures, you must submit a request in writing, stating a time period that is within six years from the date of your request. The first accounting provided within a 12- month period will be free; for further requests, we may charge you our costs. Right to Request a Paper Copy of this Notice.You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting WHCH. In addition, you may obtain a copy of this Notice on our website,www.whcommunityhouse.org. Right to Request Confidential Communications.You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests. Right to Notification of Breach of Security.You have the right to be notified of an unauthorized disclosure of your unsecured personal health information and we will notify you of such a breach in accordance with our obligations under the law. Connecticut Only Requirement V.SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. Except as provided below and as specifically permitted or required under state or federal law, health information relating
Page 7 to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization or a court order, or both. Psychiatric information.If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed between your treatment team members. Certain limited information may be disclosed for payment purposes. HIV related information.Under limited circumstances, HIV-related information may be disclosed for purposes of treatment or payment. Substance abuse treatment.If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies. VI.FOR FURTHER INFORMATION OR TO FILE A COMPLAINT If you have any questions about this Notice or would like further information concerning your privacy rights or wish to make any requests, opt-out of receiving certain communications or object to a disclosure, please contact WHCH Privacy Officer at the address listed below. If you believe that your privacy rights have been violated, you may file a complaint in writing with West Haven Community House or with the Office for Civil Rights in the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201. Complaint may also be made by phone to 1-877-696-6775. We will not retaliate against you if you file a complaint. WEST HAVEN COMMUNITY HOUSE WHCH Privacy Officer 227 Elm Street West Haven, CT 06516 (203) 934-5221
WEST HAVEN COMMUNITY HOUSE ASSOCIATION, INC. 227 ELM STREET, WEST HAVEN, CT 06516TELEPHONE: 934-5221FAX: 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.