Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please call 203-458-4040
The effective date of this privacy notice is 03/31/03
At SARAH, Inc., we respect the privacy and confidentiality of your health information. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your medical/health information and how you can get access to this information. This Notice applies to uses and disclosures we may make of all your health information whether created or received by us.
I. OUR RESPONSIBILITIES TO YOU
We are required by law to:
1. Maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices.
2. Comply with the terms of our Notice currently in effect.
We reserve the right to change our practices and to make the new provisions effective for all health information we maintain, including both health information we already have and health information we create or receive in the future. Should we make material changes, we will make the revised Notice available to you on the SARAH, Inc. website and all SARAH, Inc. locations.
II. HOW WE WILL USE AND DISCLOSURE YOUR HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
We may use and disclose your health information for purposes of treatment, payment and health care operations as described below.
1. For Treatment. We may use and disclose your health information to provide you with treatment and services and to coordinate your continuing care. Your health information may be used by doctors and nurses, as well as by lab technicians, dieticians, physical therapists or other personnel involved in your care, both within [our office or facility] and with other health care providers involved in your care. For example, a pharmacist will need certain information to fill a prescription ordered by your doctor. We may also disclose your health information to persons or facilities that will be involved in your care after you leave [our facility or our care].
2. For Payment. We may use and disclose your health information so that we can bill and receive payment for the treatment and services you receive. For billing and payment purposes, we may disclose your health information to an insurance or managed care company, Medicare, Medicaid or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request approval for a proposed treatment or service.
III. OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT
YOUR WRITTEN AUTHORIZATION
Under the Privacy Regulations, we may make the following uses and disclosures without obtaining a written Authorization from you:
1. As Required By Law. We may disclose your health information when required by law to do so.
2. Public Health Activities. We may disclose your health information for public health activities.
3. 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 and disclose your health information to notify a government authority, if authorized by law or if you agree to the report.
4. Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. A health oversight agency is a state or federal agency that oversees the health care system. Some of the activities may include, for example, audits, investigations, inspections and licensure actions.
5. 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.
6. Law Enforcement. We may disclose your health information for certain law enforcement purposes, including, for example, to file reports required by law or to report emergencies or suspicious deaths; to comply with a court order, warrant, or other legal process; to identify or locate a suspect or missing person; or to answer certain requests for information concerning crimes.
7. To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person, we may use or disclose your health information to someone able to help lessen or prevent the threatened harm.
8. National Security and Intelligence Activities; Protective Services for the Patient and Others. We may disclose health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the Patient of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.
9. Workers’ Compensation. We may use or disclose your health information to comply with laws relating to workers’ compensation or similar programs.
10. Disaster Relief. We may disclose health information about you to an organization assisting in a disaster relief effort.
11. Fundraising Activities. We may also disclose contact information for fundraising purposes to a foundation related to SARAH, Inc.
12. Business Associates. We may disclose your health information to our business associates under a Business Associate Agreement.
IV. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR ALL OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION
1. We will obtain your written authorization (an “Authorization”) prior to making any use or disclosure other than those described above.
2. A written Authorization is designed to inform you of a specific use or disclosure, other than those set forth above, that we plan to make of your health information. The Authorization describes the particular health information to be used or disclosed and the purpose of the use or disclosure. Where applicable, the written Authorization will also specify the name of the person to whom we are disclosing the health information. The Authorization will also contain an expiration date or event.
3. You may revoke a written Authorization previously given by you at any time but you must do so in writing. If you revoke your Authorization, we will no longer use or disclose your health information for the purposes specified in that Authorization except where we have already taken actions in reliance on your Authorization.
V. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding your health information:
1. Right to Request Restrictions. You have the right to request that we restrict the way we use or disclose your health information for treatment, payment or health care operations. However, we are not required to agree to the restriction. If we do agree to a restriction, we will honor that restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your treatment.
2. Right to Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.
3. Right of Access to Personal Health Information. You have the right to inspect and, upon written request, obtain a copy of your health information except under certain limited circumstances.
We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to health information, in some cases you will have a right to request review of the denial. This review would be performed by a licensed health care professional designated by SARAH, Inc. who did not participate in the decision to deny access.
4. Right to Request Amendment. You have the right to request that we amend your health information. 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 us, unless you provide reasonable information that the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by us; (c) is information to which you do not have a right of access; or (d) is already accurate and complete, as determined by us.
If we deny your request for amendment, we will give you a written denial notice, including the reasons for the denial. In that event, you have the right to submit a written statement disagreeing with the denial. Your letter of disagreement will be attached to your medical record.
5. Right to 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 us or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.
You must submit your request in writing and you must state the time period for which you would like the accounting. The accounting will include the disclosure date; the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; and a brief statement of the purpose of the disclosure. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs for completing the accounting.
6. Right to 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. [In addition, you may obtain a copy of this Notice at our website, www.sarah-inc.org.]
VI. SPECIAL REGULATIONS 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 information, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or a court orders the disclosure. A general release of your health information will not be sufficient for purposes of disclosing psychiatric, substance abuse or HIV-related information.
1. Psychiatric information. We will not disclose records relating to a diagnosis or treatment of your mental condition between the patient and psychiatrist, or which are prepared at a mental health facility, without specific written Authorization or as required or permitted by law.
2. HIV-related information. HIV-related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written Authorization. A general authorization for release of medical or other information will not be sufficient for purposes of releasing HIV-related information. As required by Connecticut law, if we make a lawful disclosure of HIV-related information, we will enclose a statement that notifies the recipient of the information that they are prohibited from further disclosing the information.
3. Substance abuse treatment. If you are treated in a specialized substance abuse program, information which could identify you as an alcohol or drug-dependant patient will not be disclosed without your specific Authorization, except where specifically required or allowed under state or federal law.
VIII. COMPLAINTS
1. If you believe that your privacy rights have been violated, you may file a complaint in writing with us or with the Office of Civil Rights in the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Room 509 F, HHH Building, Washington D.C. 20201.
2. To file a complaint with us, you should contact:
Privacy Officer
SARAH, Inc.
1620 Boston Post Road., Ste. 200
Westbrook, CT 06498
860-399-1888
3. We will not retaliate against you in any way for filing a complaint against SARAH, Inc.
