Liberty

Notice of Privacy Practices

Effective: April 14, 2003

This notice describes how 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 contact Liberty’s Privacy Officer who is Irene Bollen, Director of Quality Enhancement at (518) 954-2028.

This notice describes how protected information (medical, clinical, and other personal information) about the people served by Liberty may be used and disclosed to carry out treatment, payment, or program operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected information.

Information pertaining to HIV, alcohol and substance abuse treatment, mental health and genetics is highly sensitive and has additional protections under federal and state law. You may request a copy of our policy regarding disclosure of this information.

Liberty is required to abide by the terms of this Notice. We may change the terms of our Privacy Notice, at any time. The new Notice will be effective for all protected information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or by asking for one from you program site. A copy of the current Notice will be displayed in our reception areas at all times.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A general consent will be obtained from you regarding our ability to use and disclose information about you for the following purposes:

Treatment: We will use and disclose your protected information to provide, coordinate, or manage your health care and any related treatment. This includes the coordination or management of your health care with a third party that already has obtained your permission to have access to your protected health information. For example, Liberty will disclose protected information, as necessary, to a health provider such as doctor, hospital, therapist who provides care to you. Liberty will also disclose protected information to a physician or therapist to whom you are being referred for services. This is done to ensure that you receive coordinated treatment and services.

Treatment also includes sharing clinical information inside our agency to plan for and provide services to you. (Example: the treatment team, sharing information between Agency programs). We may also disclose certain information about you with other providers of services. (For example, we may disclose certain information about you to a prospective employer in connection with a job placement or training program.)

Payment: Your protected information will be used, as needed, to obtain payment for your services. This may include sharing information to determine whether you are eligible for a service or whether the service is covered by the insurance/funding sources. At Liberty, examples include: Office of Mental Retardation and Developmental Disabilities (OMRDD), Office of Mental Health (OMH), Medicaid, and Medicare.

Program Operations: Liberty may use your protected information or share it with others in order to conduct our normal program operations. For example, Liberty may use your protected information to evaluate the performance of our staff in providing services and supports to you. Liberty may also share your protected information with another company that performs business services for the agency (e.g. computer consulting company or other consultants). These are “business associates” and a written contract will be maintained that contains terms that will protect the privacy of your information.

Appointment Reminders, Treatment Alternatives, Benefits and Services: Liberty may use your protected information to contact you with a reminder that you have an appointment at our program. We may also use or disclose your information, as necessary, to provide you with information about treatment alternatives or health related benefits and services that may be of interest to you. For example, we may use your name and address to send you a newsletter about the services we offer. We also may send you information about products or services that we believe might be of interest and/or benefit to you. You may contact your service coordinator (or counselor, or job coach) or the Privacy Officer (Irene Bollen) to request that these materials not be sent to you.

Fundraising: Liberty may use demographic information about you, including information about your age, where you live or work, and other demographics in order to contact you to raise money to help Liberty operate. (For example, Liberty’s annual membership campaign). You may contact your service coordinator (or counselor, or job coach) or Privacy Office (Irene Bollen) to request that you not be contacted for this purpose.

Other permitted and required uses and disclosures that may be made without your consent or authorization.

Required by law: We may use or disclose your protected information if we are required by law to do so, or if a court orders us to do so in a lawsuit or judicial proceeding. We also will notify you of these uses and disclosures if notice is required by law.

Public Health: We may disclose your protected health information for public health activities to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We also may disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Disease: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Program Oversight: We may disclose your protected health information to a governmental agency for activities authorized by law, such as audits, investigations, and inspections. These governmental agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with regulatory programs and civil rights law.

Personal Representative: We may disclose protected information to a person who is authorized to make health care decisions on your behalf.

Abuse or Neglect: We may disclose your protected information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. (Examples: OMRDD, Commission on Quality Care (CQC), District Attorneys Office, Mental Hygiene Legal Services (MHLS).

Product Monitoring and Recalls: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product recalls; to make repairs or replacements, or in connections with post-marketing surveillance, as required by law.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Attorney Representing You: We will disclose protected information to an attorney representing you in an involuntary hospitalization or medication proceeding. We will not disclose clinical information about you to an attorney for any other reason without your authorization, unless we are ordered to do so by a court.

Licensed Agency Emergency Services: We will disclose protected information permitted under Federal and State confidentiality laws.

Law Enforcement: We may disclose your health information to law enforcement officials for the following reasons:

• To comply with court orders or laws that we are required to follow;
• To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;
• If you have been a victim of a crime and we determine that: (1) we have been unable to obtain your consent because of an emergency or your incapacity: (2) law enforcement officials need this information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these offices is in your best interest;
• If we suspect that your death resulted from criminal conduct;
• If necessary to report a crime that occurred on our property; or
• If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).

To Avert A Serious Threat To Health Or Safety: We may use your health information or share it with others when necessary to prevent a serious threat to your health or safety, or the health or safety of another person or the public. In such cases, we will only share your information with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have cause serious physical risks.

Victims of Abuse, Neglect or Domestic Violence: We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we may report your information to government officials if we reasonably believe that you have been a victim of abuse, neglect, or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected information of individuals who are Armed Forces personnel for authorized military purposes, as required by law.

Workers’ Compensation: Your protected information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: We may use or disclose your protected information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal privacy regulations.

Coroners, Medical Examiners and Funeral Directors: In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation: In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.

Research: In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your authorization if we obtain approval through a special process to ensure that research without your authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your health information without your authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death, we may share you health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.

Uses and disclosures of protected health information based upon your written authorization.

Other uses and disclosures of your protected information will be made only with your written authorization, unless otherwise permitted or required by law as previously described. You may revoke your authorization at any time, in writing, except to the extent that Liberty has taken an action in reliance on the use or disclosure indicated in the authorization.

Other permitted and required uses and disclosures that may be made with you permission or opportunity to object.

Friends and family Involved in Your Care: If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your location and general condition here at our facility, or about the unfortunate event of your death. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons. Liberty will disclose information to a personal representative who is authorized to make health care decisions on your behalf.

Agency Directory: Liberty will include your name and program location in our Agency Directory. This directory information will be used to forward calls and information to you. It will not be released unless the party requesting the information can identify themselves as a family member, or the release of information is required by law.

Incidental Disclosures: While we will take reasonable steps to safeguard the privacy of your protected information, certain disclosures of your information may occur during or and as an unavoidable result of our otherwise permissible uses or disclosures of your information. For example, during the course of conducting program operations other consumers in the area may see or overhear discussion of your information.

WHAT INFORMATION IS PROTECTED

We are committed to protecting the privacy of clinical information we gather about you while providing services. Some examples of protected clinical information are:

• the fact that you are a participant at, or receiving services from, our agency;
• information about your condition;
• information about health care products or services you have received or may receive in the future (such as medication or equipment); or
• information about your health care benefits under an insurance plan (such as whether a prescription is covered);

when combined with:

• geographic information (such as where you live or work);
• demographic information (such as your race, gender, or ethnicity);
• unique numbers that may identify you (such as your social security number, your phone number, or your Medicaid number); and
• other types of information that may identify who you are.

2. YOUR RIGHTS

We want you to know that you have the following rights to access and control your information. These rights are important because they will help you make sure that the information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you.

A. Right to Inspect and Copy Records: this means you may inspect and obtain a copy of protected information about you that is contained in our record(s). We may charge you our standard fee for the costs of copying, mailing or other supplies we use to fulfill your request.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding and protected health information that is subject to law that prohibits access. In some circumstances, you may have a right to have this decision reviewed. Please contact your service coordinator (or counselor or job coach) if you have questions about access to your record. A separate policy applies to psychotherapy notes and is available upon request.

We will respond to your request for inspection of records within 10 days. We ordinarily will respond to requests for copies within 30 days if the information is located in our facility and within 60 days if it is located off-site at another facility. If we need additional time to respond to a request for copies, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.

B. Right to Request Amendment of Records: If you believe that the information we have about you is incorrect or incomplete, you may ask us to change the information. You have the right to request an amendment for as long as the information is kept in our records. To request an amendment, please write to your service coordinator (or counselor or job coach). Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.

If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement, which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written notice we send you.

C. Right to an Accounting of Disclosures: After April 14, 2003, you have a right to request an “accounting of disclosures” which is a list that contains certain information about how we have shared your information with others. An accounting list, however, will not include any information about:

• Disclosures we made to you;
• Disclosures we made pursuant to your authorization;
• Disclosures we made for treatment, payment or health care operations;
• Disclosures made in the facility directory;
• Disclosures made to your friends and family involved in your care or payment for your care;
• Disclosures made to federal officials for national security and intelligence activities;
• Disclosures that were incidental to permissible uses and disclosures of your clinical information;
• Disclosures for purposes of research, public health or our normal business operations of limited portions of your clinical information that do not directly identify you;
• Disclosures about inmates to correctional institutions or law enforcement officers;
• Disclosures made before April 14, 2003.

  To request this accounting list, please write to: Irene Bollen, Privacy Officer. Your request must state a time period within the past six years (but after April 14,2003) for the disclosures you want us to include. For example, you may request a list of the disclosures that we made between January 1, 2004 and January 1, 2005. You have a right to receive one accounting list within every 12-month period for free. However, we may charge you for the cost of providing any additional accounting list in that same 12-month period. We will always notify you of any cost involved so that you may choose to withdraw or modify your request before any costs are incurred.

  Ordinarily we will respond to your request for an accounting list within 60 days. If we need additional time to prepare the accounting list you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting list. In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.

  D. Right to Request Additional Privacy Protections: You have the right to request that we further restrict the way we use and disclose your information for treatment, to collect payment for services, or to run Liberty’s normal program operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery you had. To request restrictions, please write to your service coordinator (or counselor or job coach). Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.

  We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.

  E. Right to Request Confidential Communications: You have the right to request that we communicate with you about your medical or clinical matters in a more confidential way by requesting that we communicate with you by alternative means or at alternative locations. For example, you may ask that we contact you by fax instead of by mail, or at work instead of at home. To request more confidential communications, please write to your service coordinator (or counselor or job coach). We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location.

  F. You have the right to obtain a paper copy of this Notice from us. Please call Irene Bollen, (518) 954-2028. You may also obtain a copy from our website: www.libertyarc.org

  G. Additional Information on Rights:

  How to Obtain a Copy of Revised Notice: We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. The revised notice will apply to all of your information, and we will be required by law to abide by its terms. We will post any revised notice in our agency reception area. You will also be able to obtain your own copy of the revised notice by accessing our website at www.libertyarc.org, calling our office at (518) 954-2028, or asking for one at the time of your next visit. The effective date of the notice will always be noted in the top right corner of the first page.

  How Someone May Act on Your Behalf: You have the right to name a personal representative who may act on your behalf to control the privacy of your clinical information. Parents and guardians will generally have the right to control the privacy of clinical information about minors unless the minors are permitted by law to act on their own behalf.

  How to Learn About Special Protections for HIV, Alcohol and Substance Abuse, and Genetic Information: Special privacy protections apply to HIV – related information, alcohol and substance abuse treatment information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your clinical record(s) include this type of information, you will be provided with separate notices explaining how the information will be protected. To request copies of these other notices now, please contact your service coordinator (or counselor or job coach) at (518) 842-5080.

  3. COMPLAINTS

  You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

  You may contact our Privacy Officer, Irene Bollen, at (518) 954-2028 for further information about the complaint process.