Bell Socialization Services, Inc.
Notice of Privacy Practices
Effective: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW THE REQUIREMENTS OF THIS NOTICE:
This notice describes our agency’s practices and those of:
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this agency. 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.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
HOW MAY WE USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information.
– For Treatment We may use medical information about you to provide you with behavioral health and medical treatment or services (i.e., doctors, nurses, counselors, or healthcare professionals in training). Different departments or programs of the agency may share your medical information in order to coordinate the different things you need, such as prescriptions, counseling, and residential support.
– For Payment We may use and disclose medical information about you so that the treatment and services you receive at the agency may be billed to and payment may be collected from you, and insurance company or a third party (i.e., insurance companies, MH/IDD, Medicaid and managed care organizations).
– For Healthcare Operations We may use and disclose medical information about you for agency operations. These uses and disclosures are necessary to run the agency and make sure that all of our clients receive quality care. For example, we may use medical information to review our treatment and services to evaluate the performance of our staff in caring for you. There are also some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. However, we require the business associate to appropriately safeguard your information.
– Appointment Reminders We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or services at this agency.
– Treatment Alternatives We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
– Health-Related Benefits and Services We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
– Research Under certain circumstances, we may use and disclose medical information about you for research purposes. We will also ask for specific permission if the researcher will have access to your name, address or other information that reveals your identity.
– Required By Law We will disclose medical information about you when required to so by federal, state or local law (i.e., suspected abuse or in response to a court order).
– To Avert a Serious Threat to Health or Safety We may use and disclose medical information about you 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 only be to someone able to help prevent the threat.
– Workers’ Compensation We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
– Public Health Risks We may disclose medical information about you for public health activities. These activities generally include the following:
– Health Oversight activities We may disclose medical information 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 medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery requests or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information.
– Law Enforcement We may release medical information if asked to do so by a law enforcement official:
– Coroners, Medical Examiners, Funeral Directors and Organ Donation We may release medical information to a coroner or medical examiner to identify a deceased person, determinations of a cause of death, organ donation and related reasons. We may also disclose information to funeral directors to carry out funeral-related duties.
– Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information to the correctional institution or law enforcement official to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
– Right to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy your medical information, you must submit your request in writing to the Director of Services. We will respond to your request within 30 days. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed.
– Right to Amend If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. Your request must be made in writing and submitted to the Director of Services. In addition, you must provide a reason that supports your request. We will respond to your request within 60 days. We may deny your request for an amendment 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 information that:Was not created by the Agency.
– Right to an Accounting of Disclosures You have a right to get a list of when, to whom, for what purpose, and what content of your medical information has been released other than instances of disclosure: for treatment, payment, and operations; to you, your family, or pursuant to your written authorization on or after April 2003. We will respond to your written request to the Privacy Officer within 60 days. Your request must state a time period that may not be longer than six years and may not include dates before April 15, 2003. There will be no charge for up to one such list per year. 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 a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations such as to a health care plan when you choose to pay out of pocket in full for health care services associated with a specific visit. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
– Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests. You must specify how or where you wish to be contacted.
– Right to a Paper Copy of This Notice You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request. A copy of this Notice will also be posted in each of our offices. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.
If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, you may file a complaint without fear of retaliation or intimidation to the person listed below. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775.
Contact Person for Information, or to Submit a Complaint:
If you have questions about this Notice or any complaints about our privacy practices, you should contact:
Ivan Hileman, Executive Director, Privacy Officer
160 South George Street
York, PA 17401
Call: (717) 848-5767 Ext.500
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. It is also important to note BSS will not sell your PHI without your written authorization or use identifiable PHI in marketing or fundraising activities.
Client Name (please print)
acknowledge receipt of the Bell Socialization Services, Inc. Notice of Privacy Practices.