Family Service Privacy Policy
B. The Consumer’s Right to Confidentiality and Privacy
It is the policy of Family Service that the relationship between the consumer and the Agency is confidential. Family Service recognizes that there are times when confidentiality must be broken in order to prevent serious injury either to the consumer or to another person. For example, New Jersey State law mandates that any person who has witnessed or has other knowledge of possible child abuse or neglect report this suspicion to the Division of Youth and Family Services. Certain other situations may permit Family Service to disclose information. They include, but are not limited to, treatment, payment, healthcare operations, disclosures made without identifying information, disclosures in medical emergencies, disclosures made as a result of a crime on Agency premises or against Agency staff; and disclosures made under proper court order.
Notice of Privacy Practices
Family Service’s Notice of Privacy Practices describes how consumers’ healthcare and service information may be used and disclosed. The Notice of Privacy Practices (X:\Forms\Clinical\NoticeofPrivacyPractices.doc) is required for compliance with the Health Insurance and Accountability Act of 1996. A signed acknowledgment of receipt or a documented good faith effort to obtain a signed acknowledgment is required for all admissions to Family Service on or after 4/14/2003. Consumers enrolled prior to 4/14/2003 shall receive a Notice of Privacy Practices during their next treatment plan or IHP review.
The Notice of Privacy Practices pertains to enrollment in any Family Service program. An acknowledgment is not required by individual programs when the consumer is enrolled in multiple programs.
For example, if a consumer enrolls in Family Service program A, and later enrolls in Family Service program B, program B can copy the acknowledgment of receipt completed by program A. Also, if a consumer transfers to from program A to program B, program B can copy the acknowledgment of receipt completed by program A. However, if enrollment in the first program in the episode of care was prior to 4/14/2003, the first program of enrollment on or after 4/14/2003 completes the Notice of Privacy Practices. A signed acknowledgment of the Notice of Privacy Practices is valid for six years.
The first program of enrollment in an episode of care shall review the Notice of Privacy Practices with the consumer at the first face-to-face meeting. After reviewing the notice with the consumer, the program shall attempt to obtain the consumer’s signature on the acknowledgment of receipt on page one of the notice.
If the consumer refuses to sign, the program shall document the attempt to obtain the consumer’s signature on page one of the Notice of Privacy Practices. The program representative’s signature and date must be included. A program witness shall confirm the effort by signing and dating page one of the notice. In addition, a progress note shall reflect the attempt to obtain the consumer’s signature. The program shall attempt to get the consumer’s signed acknowledgment of receipt of the Notice of Privacy Practices (X:\Forms\Clinical\NoticeofPrivacyPractices.doc) at the next face-to-face meeting. If the consumer still refuses to sign, the program shall document the second attempt on page one of the notice and in a progress note. A program witness shall confirm the second effort to obtain the consumer’s signature by signing and dating page one of the notice. In keeping with our caring culture, if the consumer refused to sign the acknowledgment of receipt for one program, all successive programs shall attempt to obtain the consumer’s signature and document the attempts as detailed above.
A copy of the signed acknowledgment of receipt of the Notice of Privacy Practices shall be placed in the Rights and Consent Section of the chart (section 2). If the consumer refuses to sign, page one of the notice including documentation of the program’s good faith effort to obtain the consumer’s signature shall be placed in the Rights and Consent Section of the chart (section 2).
A consumer may request a copy of the Notice of Privacy Practices (X:\Forms\Clinical\NoticeofPrivacyPractices.doc) at any time. Copies can be obtained from the program, the Agency’s Privacy Officer or the Family Service website, based upon the consumer’s preference. A current revision of the notice shall be available on the Family Service website at www.family-service.com, effective 4/14/2003. A current revision shall also be posted at each program, effective 4/14/2003. Revisions to the notice shall be distributed to programs using the Agency’s Policy/Form Implementation process.
Programs shall post the current Notice of Privacy Practices (X:\Forms\Clinical\NoticeofPrivacyPractices.doc) in their program. Existing consumers shall be notified of changes to the Notice of Privacy Practices during their treatment plan or IHP reviews. The current Notice of Privacy Practices shall also be reviewed during the annual Family Service Consumer Rights Week.
Subpoena
Family Service is prohibited by the New Jersey Community Mental Health Act from sending mental health information in response to a subpoena. Information can be released if the subpoena is accompanied by a consumer authorization or court order. The requesting attorney must be notified in writing that we are prohibited from sending mental health information within the designated timeframe specified by the subpoena.
All subpoenas shall be forwarded to the Program Supervisor or Program Manager immediately. Legal counsel is required for all subpoenas. The Program Supervisor or Program Manager may send the subpoena to the Privacy Officer to prepare the response and contact legal counsel for approval; or the Program Supervisor or Program Manager may prepare a response and contact legal counsel for approval directly.
Calls from lawyers regarding subpoenas shall be forwarded to the Program Supervisor, Program Manager or Privacy Officer.
The basic responsibility for determining when confidentiality must be broken rests with the worker and her/his supervisor. When serious or ambiguous situations arise staff must consult the President & C.E.O. or her/his designee. If necessary a meeting of the Ethics Committee will be called. The decision of the President is final and considered the policy of the Agency. The President may consult members of the Board of Trustees as s/he deems appropriate.
Family Service staff members may not share information regarding a consumer of the Agency, including the fact that the person is or was a consumer at Family Service, with anyone outside the Agency unless it is for purposes of treatment, payment of healthcare operations, without the written authorization of the consumer. In limited circumstances, which must be approved by the Program Supervisor/Manager or a member of the executive management staff, a worker may share information after receiving a verbal consent from the consumer. These circumstances must always be followed by obtaining a written consent.
Obtaining written authorization to release information includes filling out a Authorization to Release Information (X:Forms\Clinical\AuthorizationtoReleaseInfo) form and following these guidelines:
At admission ask the consumer to sign a form for each source that we plan to consult on an on-going basis (the DYFS worker, for example) and for each source we plan to ask for previous treatment records;
A release form is obtained each time a request for information is received from a new person or organization;
The full purpose and consequences of the release of information must be explained to the consumer in a way, or language, that s/he understands;
Each release form must include the date it is signed and the date (six months to one year hence, depending on the funding source) when the release will expire;
An updated authorization for the release of information, for on-going requests, must be obtained on or before the expiration date;
Each release form must be filled out completely, containing the name and signature of the consumer or her/his parent/guardian; the name of the program; the name of the recipient; the purpose or need for this information; the extent or nature of the information; a statement that the release is revocable; the date; the expiration date; and the signature of the worker as a witness to the consumer’s signature;
Consumers must never be asked to sign a blank release form, in the interests of expediency or for other reasons.
When the Agency receives an authorization form initiated by another organization we may release information only after this form has been examined to see that it meets our standards for releasing information.
Please see the Confidentiality of Clinical Records and the Confidentiality Policy for Administration/Accounts Receivable sections of the Management of Information manual for further information on maintaining confidentiality.
Protecting the Confidentiality of Consumers with an AIDS/HIV Diagnosis
Family Service staff members may not share information regarding a consumer of the Agency, including the fact that the person is or was a consumer at Family Service, with anyone outside the Agency without the written consent of the consumer. When a Family Service consumer discloses an HIV diagnosis additional precautions are taken to ensure that the HIV status is not disclosed without the consumer’s written consent to release this specific information to the specified recipient. This limitation includes programs and services within Family Service, such as those that are also providing a service to the consumer. Documentation in the medical record may occur only with the written authorization of the consumer. The consumer’s medical record may not be used for administrative purposes, such as billing, quality assurance, or risk management. Follow up care for AIDS/HIV, such as making a referral, is determined by the expressed wishes of the consumer and her/his written consent, as needed.
Information disclosed to authorized users is strictly limited to fulfill the purpose of the authorization. Authorizations for the release of “any and all information” without the specific mention of HIV status are not honored. A specific release of information form is used when disclosing HIV information. The required elements of the written consent for disclosure include:
The name of the consumer;
The name of the program permitted to make the disclosure;
The name of the organization/program or the title of the individual to which the disclosure is made;
The purpose of the disclosure;
How much and what type of information to be disclosed;
The consumer’s signature;
The date the consumer signed the release;
A statement that the consent is subject to revocation at any time except to the extent that the person making the disclosure has already acted on reliance of the consent;
The date, event, or condition upon which the consent will expire, if not previously revoked;
The signature and title of the person witnessing the consumer’s signature;
A statement that the information has been disclosed from records protected by Federal (42 C.F.R. Part 2) and State (New Jersey Public Law 303) confidentiality rules. These rules prohibit any further disclosure of this information without the written consent of the consumer or as otherwise permitted by law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
Within program services, information regarding a consumer’s HIV status is maintained on a need to know basis, meaning that the information is limited to specific treatment team members. HIV status may be disclosed in circumstances where appropriate safeguards must be taken to ensure the safety of staff and other consumers, such as in a residential setting.
If a consumer self-discloses information regarding her/his HIV status, to staff or to other consumers, Family Service will neither document nor disclose this information further without the express written consent of the consumer.
In the event HIV information is documented in the Consumers’ records, the closed records of these consumers are maintained with other medical records in a secure area with restricted access. The records are marked in an obscure manner to prevent the inadvertent release of HIV information. Responses to general requests for information are provided in a manner which does not identify the consumer’s HIV status, even if this means leaving out critical information such as diagnosis or health status.
