COMMUNITY SUPPORT AGENCY, LLC
PRIVACY NOTICE
THIS NOTICE DESCRIBES
HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
WE ARE REQUIRED BY LAW TO PROTECT HEALTH
CARE INFORMATION ABOUT YOU
We are required by law to protect the privacy
of health care information about you and that identifies you. This
may be information about health care services that we provided to
you. It may also be information about your past, present, or future
health care condition.
We
are also required by law to provide you with this Privacy Notice
explaining our legal duties and privacy practices with respect to
health care information. We are legally bound to follow the terms of
this Notice. In other words, we are only allowed to use and disclose
health care information in the manner that we have described in this
Notice.
We may change the terms of this Notice in the
future. We reserve the right to make changes and to make the new
Notice effective for all health care information that we maintain.
If we make changes to the Notice, we will:
• Post the new Notice in our waiting area
• Have copies of the new Notice available upon
request
• Post the new Notice on our website located at
www.1csa.net
Understanding Your Health Record and
Information
Each time you visit a hospital, physician or
other healthcare provider, a record of your visit is made.
Typically, this record contains your symptoms, examination and test
results, diagnosis, treatment and a plan for future care or
treatment. This information, which is often referred to as your
health or medical record, serves as a basis for planning your care
as well as a legal document describing the care you received.
Authorization-
As a general rule, Community Support Agency
will not disclose healthcare information about you outside our
organization without authorization (signed permission) from you or
your legally responsible person/personal representative unless
otherwise permitted/required by state and federal
confidentiality/privacy laws. If you sign an authorization allowing
us to disclose healthcare information about you, you may later
revoke or cancel it (except in very limited
circumstances
related to insurance coverage). If you would like to revoke your
authorization, you may do so orally to a Release of Information
Clerk or Medical Record Manager or in writing by filling out a
revocation form. You may obtain these forms from the receptionist at
the Community Support Agency in Delco, NC. When an authorization is
revoked, Community Support Agency will follow your instructions
except to the extent that we have already relied upon your
authorization and taken some action.
How We May Use and Disclose Your
Healthcare Information
We use and disclose healthcare information
about clients every day. This section of the notice explains in some
detail how we may use and disclose healthcare information about you
in order to provide healthcare, obtain payment for healthcare and
operate our business efficiently. As stated above, as a general
rule, Community Support Agency will not use/disclose healthcare
information about you outside our organization without authorization
from you unless otherwise permitted or required by state and federal
confidentiality/privacy laws. The following offers more description
and some examples of our potential uses/disclosures of your
healthcare information.
IF YOU ARE BEING SEEN FOR A SUBSTANCE ABUSE PROBLEM, THIS
USES/DISCLOSURE SECTION OF THE PRIVACY NOTICE DOES NOT APPLY TO
YOU. PLEASE READ THE SUBSTANCE
ABUSE USES AND DISCLOSURES SECTION.
NOTE: THE REST OF THE SECTIONS OF THIS NOTICE DO APPLY TO YOU –
RIGHTS AND HOW TO FILE A COMPLAINT.
Treatment: We will use your health information for treatment. For
example, information
obtained about you by a therapist,
psychiatrist, case manager, nurse or other member of your
healthcare team will be recorded in your
record and used to determine the course of treatment
that should work best for you. Members of
your healthcare team will also record goals that you
established and the interventions used to
help you reach your goals. Your psychiatrist will also
record information about medications they
have prescribed for you as well as your response to
these medications. We may disclose
information to other treatment providers that contract with us.
Payment: We will use your health information for payment. For
example, a bill will be sent to
you. Information on the bill may include
information that identifies you, as well as your
diagnosis, your treating clinician and
type of services you have received.
Healthcare Operations: We will use your health
information for healthcare operations. For
example, members of the treatment team and quality
improvement staff may use information in your record to assess the
care and outcomes in your case. This information will be used in an
effort to continually improve the quality
and effectiveness of the services we provide. We may
also contact you via email or phone to
provide you appointment reminders or information about treatment
choices and services that may be of interest to you.
Persons Involved in Your Care: We are required
by state law to disclose limited information
about you that is relevant to your care to: your next of kin
or other family member involved in your
care or other person designated by you. Some of the disclosures
require your written or oral authorization,
some require only that we notify you of the request.
We
may use/disclose certain healthcare information about you without
your written authorization in limited
circumstances such as: those required by law; public health
activities; health oversight activities;
disclosures about abuse, neglect or domestic violence;
judicial and administrative proceedings;
law enforcement purposes; and certain government
functions. Please note this list is NOT an exhaustive list and is
not limited to the examples listed below.
Examples of Uses/Disclosures Required by Law:
We will disclose healthcare information about
you whenever we are required by law to do so. There are many federal
and state laws that require us to use/disclose healthcare
information. or
example, state law requires us to report certain types of wounds we
think were caused by a criminal or violent act.
Examples of Uses/Disclosures for Public Health
Activities:
We may disclose healthcare information about
you when required by law for public health activities. Public health
activities require the use of medical information for various
activities, including, but not limited to, activities relating to
investigating diseases, reporting child abuse and neglect, etc. For
example, if you have been exposed to a communicable disease (such as
sexually transmitted disease) we may report it to the Health
Department.
Examples of Uses/Disclosures for Health
Oversight:
We may disclose healthcare information about
you to a health oversight agency which is an
agency responsible for overseeing the healthcare system or
government programs. For example, a government agency may request
information from us while they are investigating possible insurance
fraud.
Examples of Uses/Disclosures for
Judicial/Administrative Proceedings:
We may disclose information about you in a
judicial proceeding. For example, we must disclose
your healthcare information when we are
presented with a valid court order requiring disclosure.
Examples of Uses/Disclosures for Research:
On rare occasions Community Support Agency may
determine that information may be released for research studies.
Stringent guidelines would be met prior to such a disclosure. The
NC-TOPPS is a questionnaire which the state requires to show how you
are doing in treatment. It is completed for those ages 6 and over
with Mental Health and Substance Abuse diagnoses, and falls under
the research exception of Federal and North Carolina laws. This
means that your personal identifying information may be disclosed
without consent to the State and its evaluation contractors. The
contractors may re-disclose information only to your service
provider (s) and Community Support Agency.
Examples of Uses/Disclosures
About Abuse/Neglect:
We may disclose healthcare information about
you to a governmental authority that is authorized by law to conduct
an investigation regarding abuse and/or neglect. For example, if you
are an adult and we reasonably believe that you may be a victim of
abuse, neglect or domestic violence.
Examples of Uses/Disclosures for Law
Enforcement:
We may disclose healthcare information about
you for law enforcement purposes. For example, if a law enforcement
officer has a magistrate order to take you into custody for an
involuntary commitment exam, we are permitted to disclose to the
officer information about your mental state when necessary to assure
your health and safety and the health and safety of the officer
transporting you.
Examples of Uses/Disclosures for Governmental
Purposes:
We may use or disclose healthcare information
about you for certain governmental functions. For example, we may
disclose information to the Department of Correction if you are an
inmate and need treatment.
THIS SECTION IS FOR USES/DISCLOSURES
RELATING TO SUBSTANCE ABUSE:
Federal law, 42 CFR Part 2, restricts the use
and disclosure of patient information that is received by an alcohol
or drug abuse treatment program. Generally, substance abuse
information that we obtain for the purpose of providing you
substance abuse treatment, diagnosis, or referral for treatment must
not be disclosed without your written authorization. For example, we
would need your written authorization before we could disclose
substance abuse information to your insurance provider for the
purpose of obtaining reimbursement for the cost of services provided
to you.
The federal law protecting substance abuse
treatment information applies only to information that would
identify a substance abuse patient, directly or indirectly, as an
alcohol or drug abuser or a recipient of alcohol or drug services.
In addition to restricting disclosure, federal law places
restrictions on the use of information to initiate or substantiate
any criminal charges against a patient or to conduct a criminal
investigation of a patient.
As stated above, federal law generally requires
that we obtain your written consent before we may disclose
information that would identify you as a substance abuser or a
patient of substance abuse services. But, there are some important
exceptions to this requirement. We can disclose information within
our program to members of our workforce as needed to coordinate your
care. For example, information obtained about you by a therapist,
psychiatrist, nurse or other member of our healthcare team will be
recorded in your record and used to determine the course of
treatment that should work best for you. We may also disclose your
information to agencies that help us carry out our responsibilities
in serving you with whom we have a Qualified Service Organization or
Business Associate Agreement.
We may disclose your information within our
program to carry out our healthcare operations. For example, members
of the treatment team and quality improvement staff may use
information in your record to assess the care and outcomes in your
case. We may disclose information to medical personnel in a medical
emergency. If we suspect that a child is abused or neglected, state
law requires us to report the abuse or neglect to the Department of
Social Services, and we may disclose substance abuse treatment
information when making the report. We will disclose information
about you if a court orders us to do so. If you commit a crime, or
threaten to commit a crime, on the premises of our program or
against our program personnel, we may disclose information about you
to talk to law enforcement officers about the crime or threat. We
also may disclose information for research, audit or evaluations.
The NC-TOPPS is a questionnaire which the state requires to show how
you are doing in treatment. It is completed for those ages 6 and
over with Mental Health and Substance Abuse diagnoses, and falls
under the research exception of Federal and North Carolina laws.
This means that your personal identifying information may be
disclosed without consent to the State and its evaluation
contractors. The contractors may re-disclose information only to
your service provider(s) and Community Support Agency.
THE REST OF THIS THE SECTION APPLIES TO ALL
CLIENTS:
RIGHTS
This section of the notice will briefly mention
your privacy rights. If you would like to know more about these
rights, please contact the Client Advocate at (800) 821-6922 or the
Privacy Officer at (910) 259-0238.
Right to a Copy of Notice:
You have a right to receive a paper copy of our
Notice at any time. In addition, a copy of this notice will always
be posted in our waiting area and on Community Support Agency’s
website: http://www.1csa.net.
Right to inspect and request copy of record:
In most cases, you have the right to look at or
get copies of your records. You must make the request by writing a
letter to the Privacy Officer or filling out an Access Request Form.
You may obtain these forms from the receptionist at the Community
Support Agency in Delco, NC. We will respond to your request within
30 days. In some cases we may deny your request. If we deny you
access, we will give you written reasons for the denial and explain
any right to have the denial reviewed. If you want copies of your
record, a charge for copying may be imposed, depending on your
circumstances. You have a right to choose what portions of your
information you want copied and to have prior information on the
cost of copying.
Right to Request Amendment to Record:
If you believe that your health information is
wrong or some information is missing in your record, you must
request, in writing, that we correct or add to the record by writing
a letter to the Privacy Officer or filling out the Amendment Request
Form. You may obtain these forms from the receptionist at the
Community Support Agency location in Delco, NC. Community Support
Agency will respond within 60 days of receiving your request. We may
deny the request if we determine that the information is: (1)
correct and complete; (2) not created by us and/or not part of our
records, or; (3) not permitted to be disclosed, i.e. information
compiled in anticipation of a civil proceeding. Any denial will
state the reasons for denial and explain your rights to have the
request and denial, along with any statement in response that you
provide, added to your health information. If we approve the request
for amendment, we will change the information in your record, inform
you, and tell others who need to know about the change.
Right to Request an Accounting of Certain
Disclosures:
You have the right to request an accounting
(which means a detailed listing) of disclosures that we have made
for the previous 6 years (beginning April 14, 2003). If you would
like to receive an accounting, you may send a letter requesting an
accounting to the Privacy Officer or fill out an Accounting Request
Form. You may obtain these forms from the receptionist at the
Community Support location in Delco, NC. Our agency must act on this
request no later than 60 days after receipt of the request. The
accounting will not include several types of disclosures, including
disclosures for treatment, payment or health care operations. It
will also not include disclosures made prior to April 14, 2003. If
you request an accounting more than once every 12 months, we may
charge you a fee to cover the costs of preparing the accounting.
Right to Request a Restriction of Uses or
Disclosures:
You have the right to ask that we limit how we
use or disclose your healthcare information. You may make requests
in writing by filling out a Restriction Request Form. You may obtain
these forms from the receptionist at the Community Support location.
We will consider your request, but are not legally bound to agree
to the restriction. To the extent that we do agree to any
restrictions on our uses/disclosure of your information, we will put
the agreement in writing and abide by it except in emergency
situations. We cannot agree to limit uses/disclosures that are
required by law. In order to cancel the restrictions, you must
submit a request in writing. In addition, we may cancel a
restriction at any time as long as we notify you of the cancellation
and continue to apply the restriction to information collected
before the cancellation.
Right to Request an Alternate Method of
Contact:
You have the right to ask that we send your
healthcare or billing information to or contact you at an address or
phone number that is different than your home. We must agree to your
request as long as it is reasonably easy for us to do so. You must
make this request in writing by filling out an Alternate Contact
Request Form. You may obtain these forms from the receptionist at
the Community Support location. You do not have to explain the
reason for your request. Please be aware that if you are using a
cell phone or mobile phone, your conversations may be picked up by
other cell/mobile phone users.
Filing a Complaint
How to File a Complaint or Report a Problem:
If you believe your privacy rights have been
violated or you are dissatisfied with our privacy policies,
procedures or practice, you can file a complaint or grievance in
person or in writing with/to any appropriate staff person, the
Client Advocate or Privacy Officer. You may obtain a complaint form
from the receptionist at the Community Support location. Also, you
may file a written complaint, either on paper or electronically,
with the The Secretary of the U.S.
Department of Health & Human Services (DHHS) as follows:
Region IV, Office for Civil Rights
US Dept. of Health and Human Services
Atlanta Federal Center, Suite 3B70
61
Forsyth Street, SW
Atlanta, GA 30303-8909
Phone: (404) 562-7886
Fax: (404) 562-7881
TDD: (404) 331-2867
E-Mail:
OCRComplaint@hhs.gov
Complaints must be filed with US DHHS within
180 days of when you knew or should have known that the act had
occurred. The Secretary may waive this 180 day time limit if good
cause is shown. There will be no
retaliation against you for filing a complaint.
For More Information: If you have questions or
would like additional information, you may speak to your clinician
or contact the Client Advocate at (800) 821-6922 or the Privacy
Officer at (910) 259-0238.
