Family Service - Notice
of Privacy Practices
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This notice describes how healthcare
and service information about you may be used
and disclosed and how you
can get access to this information.Please
review it carefully.
This notice is provided to you pursuant to the Health Insurance
Portability and Accountability Act of 1996.
- Family Service is committed to protecting your personal information. We
create a record of the treatment and services you receive at
Family Service. We need this record to ensure the
quality, continuity and effectiveness of your care. In
keeping with our caring culture, Family Service strives to
maintain a balance between protecting your privacy, providing
quality treatment and ensuring your health and safety. This
notice describes how we may use and disclose your protected
health information to carry out treatment, payment, healthcare
operations, ensure your health and safety, and for other purposes
that are permitted or required by law.
- This notice also describes
your rights to access and control your protected health information. “Protected
health information” is information about you, including
demographic information such as gender, ethnicity, date of
birth, diagnosis and telephone number that may identify you
and that relates to your past, present or future physical or
mental health, condition and related healthcare services.
- Family
Service is required to abide by the terms of this Notice of
Privacy Practices. We may change the terms
of our notice at any time. A new notice will be effective
for all protected healthcare or service information that we
maintain at that time.
- A copy of the Notice of Privacy Practices
will be given to you at the time you first enroll at Family
Service (for enrollments on or after 4/14/2003). Upon
request, we will provide you with any revised Notice of Privacy
Practices. A copy
of our Notice of Privacy Practices is available on our website www.fam-serv.org.
Copies are also available from your program or the Agency’s
Privacy Officer.
Family Service Privacy Officer:
Steven Winter
609-267-5928
Suite 63, 770 Woodlane Road
Mount Holly, New Jersey 08060
Acknowledgement of Receipt
A. How we may use and disclose your healthcare and service information.
The law permits Family Service to make uses or disclosures of
your information without your consent or authorization as follows.
- Treatment: Family Service may use or disclose
your healthcare and service information to provide, coordinate
or manage your treatment.
- Example: You are enrolled in more than one Family Service
program or transfer from one Family Service program to
another. To ensure continuity of care, the programs
will share information regarding your healthcare and services. This
includes referral information received from other service
providers.
- Example: We may disclose your protected health information
to a service provider to whom you have been referred to
ensure the service provider has the necessary information
to diagnose or treat you.
2. Payment: Your protected health information
will be used, as needed, to obtain payment for your healthcare
services.
- Example: We may use/disclose your protected health information
to your insurance carrier to obtain approval for partial care
services.
- Example: Our billing department may access your protected
health information and send relevant parts to Medicaid to obtain
payment for services you receive.
3. Healthcare Operations: We may use
or disclose, as needed, your protected health information in
order to support the business activities of the Agency. These
activities include, but are not limited to, quality assessment
activities, employee review activities, training of staff and
interns, licensing and funding source reviews.
- Example: We may disclose your protected health information
to the Department of Mental Health Services for review of compliance
with regulations.
- We may use a sign-in sheet at the front desk to verify your
attendance.
- We may call your name in the waiting area when your service
provider is ready to see you.
B. There are other limited circumstances where we may
use and disclose your information without obtaining your consent
or prior authorization:
- When required by law: We may be required
by federal, state or local law to disclose your information. Examples
include suspected abuse, neglect or domestic violence; suspected
criminal activity; response to a court order or an administrative
tribunal (to the extent such disclosure is expressly authorized);
response to a subpoena when specific criteria are met, discovery
request or other lawful purposes.
- Law Enforcement : We may have to disclose
your information in conjunction with a criminal investigation
by a federal, state or law enforcement agency, as long as applicable
legal requirements are met. Examples include limited
information requests for identification and location purposes
pertaining to victims of a crime, suspicion that death has
occurred as a result of criminal conduct or in the event a
crime occurs on the premises of Family Service.
- Public
Health: We may disclose your protected
health information for public health activities and purposes
or to a public health authority that is permitted by law to
collect or receive information. The disclosure will be
made for the purpose of control and/or limiting the spread
of disease, injury or disability.
- To Avert a Serious
Threat to Health or Safety: We
may use and disclose information about you when necessary to
prevent a serious threat to your health and safety or the health
and safety of the public or another person.
- Emergencies: We
may use or disclose your information in an emergency treatment
situation.
- Health Oversight Activities: We
may disclose information to a health oversight agency for activities
authorized by law, such as audits, investigations, inspection
and licensure. Oversight agencies seeking this information
include government agencies that oversee the healthcare system,
government benefit programs, other government programs and
civil rights laws.
- Coroners, Funeral Directors and Organ
Donation: We
may disclose information to a coroner or medical examiner for
identification purposes, to determine cause of death or for
the coroner or medical examiner to perform other duties authorized
by law. We may also disclose information to a funeral
director, as authorized by law, in order to permit the funeral
director to carry out her/his duties. We may disclose
such information in reasonable anticipation of death. Information
may be used and disclosed for cadaveric organ, eye or tissue
donation purposes.
- Military and Veterans: If
you are a member of the armed forces, we may release information
about you as required by military command authorities.
- National
Security and Intelligence Activities: We
may release information about you to authorized federal officials
for intelligence, counterintelligence and other national security
activities authorized by law.
- Research: Currently
Family Service is not involved in research projects. If
in the future we are involved in research, we will only disclose
your information to researchers when their research has been
approved by an institutional review board that has reviewed
the research proposal and established protocols to ensure the
privacy of your protected health information.
C. Other Uses and Disclosures
For all other circumstances, we may only use or disclose your
healthcare and service information after you have signed an authorization. If
you authorize us to use or disclose your healthcare and service
information for another purpose, you may revoke your authorization
in writing at any time.
D. Your Rights
You have the following rights with respect to your healthcare
and service information.
- You have the right to request restrictions on the
uses and disclosures of your healthcare and service information. Requests
for restrictions must be in writing, describe what information
you wish to limit and to whom the limit applies. For
example, you may request we limit disclosures to your treating
physician or your personal psychiatrist. We will always
balance your requests against the goal of providing you with
quality treatment and ensuring your health and safety. We
are not required to comply with your request for restrictions
in regard to treatment, payment or healthcare operations. If
your service provider believes it is in your best interest
to permit use and disclosure of your information, your information
will not be restricted. If your service provider does
agree to the restriction, we will comply unless in your service
provider’s professional judgment, use or disclosure
of your information is in your best interest.
- You
have the right to request to receive confidential communications
from us by alternative means or at an alternative location. For
example, you can request that we only contact you at work
or by mail. We will accommodate
reasonable requests.
- You have the right to inspect
and copy your information. Your
request must be in writing. We will respond to requests
within 30 days. We will charge you a reasonable cost-based
fee to cover copying and/or preparation of a summary.
- You
have the right to request that we amend your information that
is incorrect or incomplete. Requests
for amendments must be in writing and must provide a reason
to support the request. We may deny your request if
it is not in writing, the information specified was not created
by Family Service, or the information specified is accurate
and complete in the professional judgment of your service
provider. If we deny your request for an amendment, you have
the right to file a disagreement with us and we may prepare
a rebuttal to your statement. We will provide you with
a copy of any rebuttal we prepare.
- You have the right
to receive an accounting of disclosures we have made of your
healthcare and service information for purposes other than
those listed in items A and
B above. You may not request an accounting
of disclosures made prior to April 14, 2003.
- You have
the right to obtain a paper copy of this notice from us. Contact
your service provider or the Privacy Officer using the contact
information supplied below.
E. Complaints
If
you believe your privacy rights have been violated, or you disagree
with a decision we made about access or amendment to your information,
you may file a written complaint with the Agency’s Privacy
Officer at the address listed below. You may also file
a written complaint with the Secretary of the U.S. Department
of Health and Human Services. We will take no retaliatory
action against you if you make such complaints.
Family Service Privacy Officer
Steven Winter
609-267-5928
Suite 63, 770 Woodlane Road
Mount Holly, New Jersey 08060
This notice was published and becomes
effective on April 14, 2003.
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