Understanding Your Mental Health, Intellectual Disability and Substance Abuse Medical Record Information

Each time you visit a hospital, a physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your assessment, service plan, progress notes, diagnoses, treatment, and plan for future care or treatment.
Danville-Pittsylvania Community Services understands that your privacy is important. Any and all information we receive about you will be used only to assist you. We will handle this information only as allowed by federal/state law and Agency policy.

Your Rights Under the Federal Privacy Standard

Although your health records are the physical property of the health care provider who completed it, you have the following rights with regard to the information contained therein:

· Obtain a copy of this Notice of Information Practices. Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.

· Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. "Health care operations" consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. Your request will be given serious consideration; however, we do not have to agree to the restriction and legally, we are not required to abide by any restrictions you request. If we do, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is reasonable, we must grant the alternate communication request. You may request restriction or alternate communications on the Privacy Notice.

· Inspect and copy your health information upon request (subject to copying and handling fees as may be permitted by law). This right is not an absolute. In certain situations, such as if access would cause harm, we can deny access. You may make this request to your assigned clinician or his/her supervisor.

· Request amendment/correction of your health information by completing the Request for Amendment/Correction of Protected Health Information form. Again, this right is not an absolute.
· Obtain an accounting of non-routine uses and disclosures, other than those for treatment, payment, and health care operations by completing the Request to Accounting of Uses and Disclosures of Protected Health Information form.

· Revoke your authorization to use or disclose health information by completing the Revocation of an Authorization form, except to the extent that we have taken action in reliance on the authorization.
How to Get More Information or to Report a Problem

If you have questions, would like additional information, would like to exercise any of your rights or wish to report a problem, you may contact the:

Privacy Officer at 434-799-0456
Danville-Pittsylvania Community Services
245 Hairston Street
Danville, Virginia 24540
State Advocate at 866-645-4510
Secretary of Health and Human Services at 1-800-368-1019

You will not suffer change in services or retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment, and Health Operations

· As a health care provider, we will use your health information for treatment.
Example: A physician, therapist, counselor, nurse, or another member of your health care team will record information in your record to diagnose your condition and determine the best course of treatment for you. The primary caregiver will give treatment orders and document what he/she expects other members of the health care team to do to treat you. Those other members will then document the actions they took and their observations. In that way, the primary caregiver will know how you are responding to treatment.

· As a health care provider, we will use your health information for payment.
Example: We may send a bill to you, to a responsible party identified by you, or to a third-party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, and treatment received.

· As a health care provider, we will use your health information for health operations.
Example: Members of the clinical staff or quality assurance team may use information in your health record to assess the care and outcomes in your case and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the health care and services that we provide.

· Business associates: We provide some services through contracts with business associates.
Examples include certain diagnostic tests or laboratory tests and the like. When we use these services, we may disclose your health information to the business associates so that they can perform the function(s) that we have contracted with them to do and bill you or your third-party payer for services provided. To protect your health information, however, we require the business associates to appropriately safeguard this information.

· Notification: We may use or disclose information to notify or assist in notifying a family member, a personal representative, or another person responsible for your care, your location, and general condition.

· Communication with family: Unless you object or as otherwise permitted by law, health professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify as being authorized, health information relevant to that person's involvement in your care or payment related to your care.

Enhancing Your Health Care
Some Agency programs provide the following support to enhance your overall health care:

· Appointment reminders by call or letter
· Describing or recommending treatment alternatives
· Providing information about health related benefits and services that may be of interest to you

Specific Circumstances for Disclosure Without Authorization or an Opportunity to Authorize or Object

We are allowed by federal and state law (in certain circumstances) to disclose specific health information about you without authorization or opportunity to authorize or object. There may be documentation available upon your request listing what information was disclosed, to whom, and for what reason. These specific circumstances are:

· Research: We may disclose information to researchers with whom you have agreed to participate, 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 health information.

· Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

· Public health authorities: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

· Correctional institution: If you are an inmate of a correctional institution, we may disclose to the institution, or agents thereof, health information necessary for your health and the health and safety of other individuals.

· Law enforcement: We may disclose health information to law enforcement authorities for purposes of reporting gunshot wounds, and other reports required by law or in response to a valid subpoena or court order.

· Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more consumers, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the Department of Health.

· Coroners, Medical Examiners, and Funeral Directors: We may disclose health information for identification of a deceased person or to determine cause of death, consistent with applicable state laws.

· As required by law: We may disclose health information as required by law.

· Judicial and administrative proceeding: We may disclose health information as required by subpoena or court order and in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal.

· To protect third parties from serious harm: We may disclose health information in response to a statement made by a person served to harm self or others.

· Government authorities about victims of abuse, neglect, or domestic violence: We may disclose health information on children or incapacitated adults who are victims of abuse, neglect, or exploitation.

· Specialized government functions: If permitted by law, we may disclose health information to military services in response to appropriate military command to assure the proper execution of the military mission; to national security and intelligence activities in relation to protective services to the President of the United States and to the State Department for medical suitability for the purpose of security clearance.

· The Federal Department of Health and Human Services (DHHS): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.

· The Department of Behavioral Health and Developmental Services (DBHDS): We may disclose health information to DBHDS as necessary to determine compliance with state and federal regulations.

A more detailed explanation of all situations allowed by federal and state law is available upon request.

Other Uses and Disclosures of Your Health Information by Authorization Only

When you request information to be disclosed to another party or yourself, we will respond within federal and state law.

We are required to obtain your authorization to use or disclose your Protected Health Information (PHI) for any reason other than treatment, payment, or health care operations, as well as those specific circumstances outlined previously. We use an Authorization for the Release of Confidential 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 given to us to that effect.
Our Responsibilities Under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the Federal Privacy Standard requires us to maintain the privacy of your health information, provide you this notice as to our legal duties and privacy practices with respect to PHI, and abide by the terms of this notice. We will not use or disclose your health information without your consent or authorization except as described in this notice or otherwise required by law.

DANVILLE-PITTSYLVANIA COMMUNITY SERVICES RESERVES THE RIGHT TO CHANGE ITS PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF WE CHANGE OUR INFORMATION PRACTICES, WE WILL MAKE THE NOTICE AVAILABLE UPON REQUEST ON OR AFTER THE EFFECTIVE DATE OF THE REVISION.

PRIVACY NOTICE SIGNATURE PAGES

I have been provided a Notice of Information Practices that fully explains the uses and disclosures that Danville-Pittsylvania Community Services will make with respect to my individually identifiable health information. Danville-Pittsylvania Community Services has afforded me sufficient time to review this Notice and has answered any questions that I had to my satisfaction.

I understand that I have the right to request restrictions on the use or disclosure of my individually identifiable health information to carry out treatment, payment, or health care operations. I further understand that Danville-Pittsylvania Community Services is not required to agree to the requested restriction but that, if it does agree, it must honor the restriction unless I request that it stop doing so or Danville-Pittsylvania Community Services notifies me that it no longer intends to honor the request. I request the following restrictions on the use or disclosure of my individually identifiable health information. 0 No Restriction 0 Restriction(s) as indicated below:
________________________________________________________________________

I understand that I have the right to request restriction as to the method of communications to me. For example, I might request that all medical bills be mailed to a post office box rather than my home. I further understand that Danville-Pittsylvania Community Services must honor this request if the method of communication is reasonable. Danville-Pittsylvania Community Services may not ask me why I want the alternate method of communication. 0 No Restriction 0 Restriction(s) as indicated below:
________________________________________________________________________

Consumer Name: ____________________________ Case Number: ____________

I understand that I have the right to object to the use and/or disclosure of my individually identifiable health information to family members. 0 No Objection
0 Objection(s) as indicated below:
________________________________________________________________________

________________________________________ ________________________
Signature of Consumer Date

________________________________________ ________________________
Signature of Legal Guardian Date

________________________________________ ________________________
Signature of Authorized Representative Date

_______________________________________ ________________________
Signature of Witness Date

Name of Provider: Danville-Pittsylvania Community Services
Effective Date: April 14, 2003

Consumer Name: ______________________________ Case Number: ____________