NOTICE OF PRIVACY PRACTICES
HOME START, INC.
Effective Date: August 31, 2006
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.
WHO WILL FOLLOW THIS NOTICE
This Notice describes Home Start, Inc.’s practices and that of:
All employees, interns, and volunteers (collectively called “staff”) of Home Start.
Any member of a volunteer group we allow to help you while you are receiving services from Home Start.
OUR PLEDGE REGARDING YOUR HEALTH INFORMATION
We understand that information about you and your health is personal, and we are committed to protecting your health information. We create a record of the care and services you receive at Home Start. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the agency. As required and when appropriate, we will ensure that only the minimum necessary information is released in the course of our duties.
This Notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations regarding the use and disclosure of health information.
We are required by law to:
Keep your health information, also known as “protected health information” or “PHI,” private;
Give you this Notice of our legal duties and privacy practices with respect to your PHI; and
Follow the terms of the Notice that are currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR PERMISSION
TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS
The following categories contain examples of how Federal law permits use or disclosure of your PHI for these purposes without your permission. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose your PHI will fall within one of the categories.
For Treatment
We create a record of the treatment and services you receive at Home Start. In the course of providing counseling/case management services to you, Home Start staff may become aware of medical information about you or a family member. Home Start staff may use that information to provide appropriate referrals to you to other agencies that may help with treatment for your medical condition and to provide appropriate case management and counseling services. We may use your PHI to provide you with medical treatment or services. We may disclose your PHI to doctors, nurses, technicians, or other personnel who are involved in taking care of you. For example, a doctor treating you for a chemical imbalance may need to know if you have problems with your heart because some medications affect your blood pressure. We may share your PHI in order to coordinate the different services you need, such as prescriptions, blood pressure checks and lab tests, and to determine a correct diagnosis.
We also may disclose your PHI to people outside the agency who may be involved in your service, such as your employment case manager or other persons, for coordination and management of your health care. Your mental health information may only be released to health care professionals outside this facility without your authorization if they are responsible for your physical or mental health care.
For Payment
We may use and disclose your PHI in order to get paid for the treatment and services we have provided you. For example, we may need to provide the Victims Compensation Program (VCP) information about a visit or treatment session you received at Home Start so the VCP will pay us. We may also tell the VCP about a treatment you are going to receive to obtain prior approval or to determine whether they will cover the treatment.
For Health Care Operations
We may use and disclose your PHI to carry out activities that are necessary to run our organization and to make sure that all of our clients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you.
OTHER SPECIAL CIRCUMSTANCES
We are permitted under federal and applicable state law to use or disclose your PHI without your permission only when certain circumstances may arise, as described below. We are likely to use or disclose your PHI for the following purposes:
Appointment Reminders
We may use and disclose your PHI to contact you as a reminder that you have an appointment for services with Home Start.
Business Associates
We provide some services through other companies termed “business associates.” Federal law requires us to enter into business associate contracts to safeguard your PHI.
Disclosures to Parents or Legal Guardians
If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law.
Treatment Alternatives and Health-Related Products and Services
We may use and disclose your PHI to recommend possible treatment options or alternatives that may be of interest to you. Additionally, we may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you. For example, if you disclose to Home Start staff that your child is in need of immunization shots, Home Start staff may provide you with information about clinics that will provide the immunization treatment.
Fundraising Activities Home Start staff may contact you during your services or after services have been completed to request that we use your poses. If you do not want Home Start to contact you for fundraising purposes, please initial the statement on your “Acknowledgement of Receipt” that says you do not want to be contacted for fundraising purposes.
Disaster Relief Purposes
We may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location in order to respond to the emergency circumstances as necessary.
As Required By Law
We will disclose your PHI when required to do so by federal, state or local law. For example, we are required by law to disclose PHI to Child Welfare Services when there is a suspicion of child abuse.
To Avert a Serious Threat to Health and Safety
We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.
Workers’ Compensation
We may release your PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks
We may disclose health information about you for public health activities, such as those aimed at preventing or controlling disease, preventing injury or disability, and reporting the abuse or neglect of children, elders and dependent adults.
Military and Veterans
If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
Health Oversight Activities
We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
Law Enforcement
We may disclose PHI to government law enforcement agencies in response to a court order, warrant, subpoena, summons or similar process issued by a court.
Research
Under certain circumstances, we may use or disclose your PHI for research purposes. However, before disclosing your PHI, the research project must be approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Coroners, Medical Examiners and Funeral Directors
We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about clients of the agency to funeral directors as necessary to carry out their duties.
Specialized Government Functions
We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
United States Department of Health and Human Services
Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.
Administrator or Executor
Upon your death, we may disclose your PHI to an administrator, executor, or other authorized individual under applicable state law.
Inmates
If you are an inmate of a correctional institution, you lose the rights outlined in this Notice. Furthermore, if you are an inmate or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
HOW WE MAY USE OR DISCLOSE YOUR PHI FOR OTHER PURPOSES ONLY WITH YOUR PERMISSION
Other uses and disclosures of your PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by the authorization. Please note that we are unable to take back any disclosures we have already made when the authorization was in effect, and we are required to retain our records of the care that we provided to you.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding your PHI in our records:
Right to Inspect and Copy
With certain exceptions, you have the right to inspect and copy your PHI from our records. Usually, this includes medical and billing records. To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing. Records will be made available for inspection after 5 business days. We require 15 business days, from the date of the written request, to provide copies of the record. Copies will be charged at a rate of .25¢ per copy. We require 10 business days to provide treatment summaries. We may deny your request to inspect and copy in certain circumstances. If you are denied the right to inspect and copy your PHI in our records, you may request that the denial be reviewed. With the exception of a few circumstances that are not subject to review, another licensed health care professional within Home Start, who was not involved in the denial, will review the decision to deny access. We will comply with the outcome of the review.
Right to Request Amendment
If you feel that your PHI in our records is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the PHI. To request an amendment, you must submit your request in writing. We will deny your request to amend psychotherapy notes. We may deny your request for an amendment of other health information if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that:
Was not created by us, unless you can provide us with a reasonable basis to believe that the person or entity that created the PHI is no longer available to make the amendment;
Is not part of the PHI kept by or for the agency;
Is not part of the PHI which you would be permitted to inspect and copy; or
Is accurate and complete.
Even if we deny your request for amendment, you have the right to submit a Statement of Disagreement, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want this Statement to be made part of your health record, we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of your PHI other than our own uses for treatment, payment and health care operations (as those functions are described above) and with other exceptions pursuant to the law.
To request this list or accounting of disclosures, you must submit your request in writing. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request that we follow additional, special restrictions when using or disclosing your PHI for treatment, payment or health care operations. For example, you could ask that we not use or disclose that you are receiving services at Home Start. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must submit your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications
You have the right to request that we communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must request this of your direct service provider. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice. You may ask your direct service provider to give you a copy of this Notice at any time. You may also obtain a copy of this Notice at our Web site: https://home-start.org.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the agency. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you engage in services with Home Start, you will receive a copy of the current Notice.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Home Start or the Federal Government. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint. To file a complaint with us, or if you have comments or questions regarding our privacy practices, contact:
Home Start, Inc.
Attn: HIPAA Privacy Officer
5005 Texas Street, Suite 203
San Diego, CA 92108
(619) 692-0727
To file a complaint with the Federal Government, contact:
Office of Civil Rights (Room 515 F)
US Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
(202) 619-0805
(202) 619-0553
______________________________________________________________________________
NOTICE OF PRIVACY PRACTICES:
Acknowledgement of Receipt
By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Home Start, Inc. (“Home Start”). Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. Our Notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a copy of the revised Notice from your direct services provider or by visiting our Website at https://home-start.org.
I,______________________________________, acknowledge receipt of the Notice of Privacy Practices of Home Start, Inc.
Signature:_________________________________________ Date:____________________
Home Start, Inc. is a nonprofit organization that engages in numerous fundraising/marketing activities. As part of our fundraising/marketing efforts, we like to incorporate successful client stories. Please initial the line below that indicates your preference about being contacted to share your story.
__________My initials here indicate that I would be willing to share my success story.
__________My initials here indicate that I would NOT be willing to share my success story.
INABILITY TO OBTAIN ACKNOWLEDGEMENT (To be completed only if no signature is obtained)
If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained.
Reasons why the acknowledgement was not obtained:
_____Client refused to sign.
_____Other or comments:_________________________________________________________
____________________________________________________________________________
Signature:__________________________________________________Date:_______________
Print Name:_________________________________________________
(client/parent/conservator/guardian)
(Home Start Representative)
Revised 03/11/09