Sample CSB Privacy Notice

Your Privacy is Important

The Harrisonburg-Rockingham CSB understands your privacy is important. We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this notice. We will handle this information only as allowed by federal/state law and agency policy, adhering to the most stringent law that protects your health information.

If at any time you believe your privacy rights have been violated, you may verbally or in writing contact:

· Agency's Privacy Officer

· Secretary of Health and Human Services

Addresses and phone numbers to use are listed at the end of this notice. You will not suffer change in services or retaliation for filing a complaint.

Each time you receive services from us, the provider makes a record of the visit. Typically, this record contains your assessment, service plan, progress notes, diagnoses, treatment, and plan for future care or treatment.

Your Federally defined rights under 45 CFR Parts 160 and 164 (HIPAA Privacy Standards), and under The Commonwealth of Virginia’s Administrative Code, Title12, sections 35-115-80 and 35-115-90 (Human Rights).

There are several rights concerning your health information in the medical record that we want you to be aware of:

* You have the right to inspect or request copies of your medical records. This process will be kept confidential. This right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You must make this request in writing to your Case Coordinator or the agency's Manager of Consumer Affairs. If denied access, you will receive a timely, written notice of the decision and reason, and a copy of this notice becomes a part of your record.

* You have the right to request amendment of your medical records if you believe information in the records is inaccurate or incomplete. You must make this request in writing to your Case Coordinator or the agency’s Manager of Consumer Affairs.

* You have the right to request an accounting of the agency’s disclosures of your protected health information as defined in HIPAA and/or Human Rights regulations.

* You have the right to request from your Case Coordinator a restriction with regards to the use or disclosure of your protected health information. This request will be given serious consideration by a Privacy Officer and you will be informed promptly whether we will be able to honor the requested restriction and still offer effective services, receive payment and maintain health care operations. Legally we are not required to agree to any restrictions you request, but if we do agree, we are bound by that agreement except under certain emergency circumstances.

* You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Such requests must be made in writing to your Case Coordinator. We will agree to all reasonable requests.

* You have the right to obtain a paper copy of the Privacy Notice at any time upon request.

Use and Disclosure of Your Information

In order to provide effective services, there will be times that the agency uses and discloses necessary information about you within the agency and with business associates in order to provide treatment/service, receive payment of provided treatment/service, and conduct our day-to-day business practices. Some examples of such uses include:

* In order to effectively provide treatment/service, your Case Coordinator may consult with other staff within the agency. During those consultations health information about you may be shared.

* In order to receive payment of services provided, your health information may be sent to those companies or groups responsible for payment coverage, and a monthly bill is sent to the Responsible Party identified by you and noted on the financial form.

* In day-to-day health care operations, trained staff may handle your physical medical record in order to have the record assembled, available for review by the service providers, or for filing of documentation. Certain data elements are entered into our computer system that processes most billing, for state statistical reporting to the Department of Mental Health, Mental Retardation, and Substance Abuse Services (The Department), and for scheduling and clinical documentation. As a part of our continuous quality improvement efforts to provide the most effective services, your record may be reviewed by professional staff to check for compliance with regulatory requirements, completeness, and organization. Records may also be reviewed by The Department.

Enhancing Your Healthcare

Some agency programs provide the following support to enhance your overall health care and may contact you to provide:

· Appointment reminders by call or letter

· Information about treatment alternatives

· Information about health-related benefits and services that may be of interest to you

Specific Circumstances for Disclosure

This agency is also allowed by federal and state law in certain circumstances to disclose specific health information about you.

These specific circumstances include:

· As required by law (ex: reports required for public health purposes, such as reporting certain contagious diseases)

· Judicial and Administrative proceedings (ex: Order from a court or administrative tribunal, or legal counsel to the agency, or Inspector General)

· Law Enforcement purposes (ex: reporting of gun shot wounds; limited information requested about suspects, fugitives, material witnesses, missing persons, criminal conduct on premises)

· To avert a serious threat to Health and Safety of another person (ex: in response to a statement made by person served to harm self or another)

· Children or incapacitated adults who are victims of abuse, neglect or exploitation

· Specialized Government functions

· Military Services (ex: in response to appropriate military command to assure the proper execution of the military mission)

· National Security and Intelligence activities (ex: in relation to protective services to the President of the United States)

· State Department (ex: medical suitability for the purpose of security clearance)

· Correctional Facilities (ex: to correctional facility about an inmate)

· Workers Compensation to facilitate processing and payment

· Coroners and Medical Examiners for identification of a deceased person or to determine cause of death

· The Department of Health and Human Services in connection with an investigation of the agency for compliance with federal regulations.

Other Uses and Disclosures of Your Information by Authorization Only

We are required to get your authorization to use or disclose your protected health information for any reason other than for treatment/services, payment, or health care operations and those specific circumstances outlined previously. We use an Authorization to Release/Receive Medical Records and/or Exchange Information form that specifically states what information will be given to whom, for what purpose, and is signed by you or your legal representative. You have the ability to revoke the signed authorization at any time by a written statement except to the extent that we have acted on the authorization.

Changes to Privacy Practices

The Harrisonburg-Rockingham CSB reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law and to make the change effective for all protected health information that we maintain. Revised Privacy Notices will be posted at all service sites, and available upon request by mailing, discussion with an agency representative, electronically, or a combination of the three.