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.

PER THE HEALTH INFORMATION PORTABILITY & ACCOUNTABILITY ACT (HIPAA) OF 1996, WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION.  We will protect the privacy of the health information that we maintain that identifies you, whether it deals with the provision or payment of your health care.  We must provide you with this Notice about our privacy practices.  It explains how, when, and why we may use and disclose your health information.  With some exceptions, we will avoid using or disclosing any more of your health information than is necessary to accomplish the purpose of the use of disclosure.  We are legally required to follow the privacy practices that are described in this Notice, which is currently in effect.

However, we reserve the right to change the terms of this Notice and our privacy practices at any time.  Any changes will apply to any of your health information that we already have.  Before we make an important change to our policies, we will promptly change this Notice and post a new Notice in our reception area.  You may also request a copy of our Notice of Privacy Practices from our Privacy Officer, the Vice President – Quality & Effectiveness.  An electronic copy of this Notice will remain available on this web site.

 We would like to take this opportunity to answer some common questions concerning our privacy practices:

Question:  How will this organization use and disclose my protected health information?

Answer:  We use and disclose health information for many different reasons.  For some of these uses of disclosures, we need your specific authorization.  Below (A through D), we describe the different categories of our uses and disclosures and give you some examples of each.

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

1.   For Treatment:  For example, we may disclose your medical history to a hospital if you need medical attention while at our facility, or to a residential care program we are referring you to.  Reasons for such a disclosure may be:  to get them the medical history information they need to appropriately treat your condition, to coordinate your care, or to schedule necessary testing.  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 disclose your health information to other health care providers who are involved in your care.

2.   To Obtain Payment for Treatment:  For example, we may provide certain portions of your health information to your health insurance company, Medicare or Medicaid, or the Office of Family & Children in order to get paid for services provided to you.  We may use and disclose necessary health information in order to bill and collect payment for the treatment that we have provided to you.  We need your specific authorization for sharing information concerning HIV status, drug and alcohol abuse and/or treatment.

3.  For Health Care Business Operations:  At times, we may 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 in order to make sure that we're complying with law.  Because this information concerns mental health disorders and/or treatment, drug and alcohol abuse and/or treatment, and/or HIV status, we may be further limited in what we provide and may be required to first obtain your authorization.

4.   Other:  Occasionally we have visitors touring our facilities in consideration of services to be provided.  No individually identifiable health information will be disclosed.

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 we are ordered by a court, or if a law requires that we report certain information to a government agency or law enforcement authorities, such as suspected child abuse.

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 County and/or 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 Organ Donation.  If one of our clients wished to make an eye, organ, or tissue donation after their death, we may disclose certain necessary health information to assist the appropriate organ procurement organization.

5.  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.

6.  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.

7.  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

8.  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.

9.  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, follow-up, or alternative services that may help you.

10.  Fundraising or Marketing Activities.  For example, if our Organization chose to raise funds to support one or more of our programs or facilities, we may use the information that we have about you to contact you. You may be asked to share your story, make a donation, or help in some other way.  Your participation would be voluntary.  If you do not wish to be contacted as part of any fundraising or marketing activities, please contact the Vice President – Development.

 C.  Certain Uses and Disclosures Require You to Have the Opportunity to Object.   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 is in a session with you or listed as a contact for your care, we may disclose otherwise protected health information to them, unless you tell us not to.

2.  Disclosures to Notify a Family Member, Friend, or Other Selected Person.  When you first started in our program, we ask that you provide us with an emergency contact person in case something should happen to you while you are under our care.  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, as long as it is revoked in writing.

Question:  What rights do I have concerning my protected health information:

Answer:  You have the following rights (A through E) 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.  A request form may be obtained from your counselor.  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.  You have a right to appeal the decision.

 If you request a copy of any portion of your protected health information, we will charge you for the copy on a per page basis.  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:

1.  uses or disclosures for treatment, payment or healthcare business operations;

2.  diisclosures to you or with your written authorization; 

3.   disclosures to individuals involved in your care (including family members, close friends, or whomever you identify to us) for notification purposes or due to their involvement in your care;

4.  disclosures made for national security purposes;

5.  disclosures made regarding adult or child protection;

6.   disclosures to corrections or law enforcement authorities; or

7.  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 upon asking your counselor.  We will respond to you within 60 days of receiving your request.  The list that you may receive will include:

1.  the date of the disclosure,

2.  the person or organization that received the information and, if known, the address of such entity or person,

3.  a brief description of the information disclosed, and

4.  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 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 information.  You must make the request in writing, stating the reason for your request, on a request form that is available from your counselor.  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 who 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 do so, you may ask that we include a copy of your request form, and our denial form, 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, please contact Vice President, Quality & Effectiveness at 317-643-6341.  You also have the right to file a written complaint with the Secretary of the U.S. Department of Health and Human Services.  Complaint forms are available at www.cms.hhs.gov/hippa/.  We cannot take any retaliatory action against you if you lodge any type of complaint.

Question:  When does this notice take effect?

Answer:  This Notice takes effect on April 14, 2003.

Approved by Board of Directors

Family Service
615 N. Alabama St.
Indianapolis, IN  46204
317-634-6341

© 2003 Family Service, All Rights Reserved.