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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
Important
Notice of Privacy Practices
Clifford
Beers Clinic
It
is important to read and understand this Notice of Privacy Practices
before signing the Consent and Acknowledgment Form.
If
you have any questions about this Notice or would like further information
concerning your privacy rights, please contact Clifford Beers Clinic.
Clifford
Beers Clinic
Shannon Browne, Privacy Officer
93 Edwards Street
New Haven, CT 06511
(203) 772-1270
Notice
of Privacy Practices
Effective Date: April 14, 2003
Purpose of the Notice of Privacy Practices
This Notice of Privacy Practices (the "Notice") is meant to
inform you of the uses and disclosures of protected health information
that we may make. It also describes your rights to access and control
your protected health information and certain obligations we have regarding
the use and disclosure of your protected health information.
Your
"protected health information" is information about you created
and received by us, including demographic information, that may reasonably
identify you and that relates to your past, present or future physical
or mental health or condition, or payment for the provision of your health
care.
We
are required by law to maintain the privacy of your protected health information.
We are also required by law to provide you with this Notice of our legal
duties and privacy practices with respect to your protected health information
and to abide by the terms of the Notice that is currently in effect. However,
we may change our notice at any time. The new revised Notice will apply
to all of your protected health information maintained by us. You will
not automatically receive a revised Notice. If you would like to receive
a copy of any revised Notice you should access our web site at www.cliffordbeers.org,
contact Clifford Beers Clinic or ask at your next appointment.
How
We May Use or Disclose Your Protected Health Information
Clifford Beers Clinic will ask you to sign a consent form that allows
Clifford Beers Clinic to use and disclose your protected health information
for treatment, payment and health care operations. You will also be asked
to acknowledge receipt of this Notice.
The
following categories describe some of the different ways that we may use
or disclose your protected health information. Even if not specifically
listed below, Clifford Beers Clinic may use and disclose your protected
health information as permitted or required by law or as authorized by
you. We will make reasonable efforts to limit access to your protected
health information to those persons or classes of persons, as appropriate,
in our workforce who need access to carry out their duties. In addition,
if required, we will make reasonable efforts to limit the protected health
information to the minimum amount necessary to accomplish the intended
purpose of any use or disclosure and to the extent such use or disclosure
is limited by law.
- For
Treatment - We may use and disclose your protected health information
to provide you with medical treatment and related services. If we are
permitted to do so, we may also disclose your protected health information
to individuals or facilities that will be involved with your care after
you leave Clifford Beers Clinic and for other treatment reasons. We
may also use or disclose your protected health information in an emergency
situation.
- For
Payment - We may use and disclose your protected health information
so that we can bill and receive payment for the treatment and related
services you receive. For billing and payment purposes, we may disclose
your health information to your payment source, including an insurance
or managed care company, Medicare, Medicaid, or another third party
payor. For example, we may need to give your health plan information
about the treatment you received so your health plan will pay us or
reimburse us for the treatment, or we may contact your health plan to
confirm your coverage or to request prior authorization for a proposed
treatment.
- For
Health Care Operations - We may use and disclose your health information
as necessary for operations of Clifford Beers Clinic, such as quality
assurance and improvement activities, reviewing the competence and qualifications
of health care professionals, medical review, legal services and auditing
functions, and general administrative activities of Clifford Beers Clinic
- Business
Associates - There may be some services provided by our business
associates, such as a billing service, transcription company or legal
or accounting consultants. We may disclose your protected health information
to our business associate so that they can perform the job we have asked
them to do. To protect your health information, we require our business
associates to enter into a written contract that requires them to appropriately
safeguard your information.
- Appointment
Reminders - We may use and disclose protected health information
to contact you as a reminder that you have an appointment at Clifford
Beers Clinic.
- Treatment
Alternatives and Other Health-Related Benefits and Services - We
may use and disclose protected health information to tell you about
or recommend possible treatment options or alternatives and to tell
you about health related benefits, services, or medical education classes
that may be of interest to you.
- Fundraising
Activities - We may use information about you to contact you in
an effort to raise money for Clifford Beers Clinic and its operations.
The information we release will be limited to your contact information,
such as your name, address and telephone number and the dates you received
treatment or services at Clifford Beers Clinic. A description of how
to opt out of receiving any further fundraising communications will
be included with any fundraising materials you receive from Clifford
Beers Clinic. If you request that your information not be used or disclosed
for fundraising purposes, we will make a reasonable effort to ensure
that you do not receive future fundraising communications.
- Individuals
Involved in Your Care or Payment of Your Care - Unless you object,
we may disclose your protected health information to a family member,
a relative, a close friend or any other person you identify, if the
information relates to the person's involvement in your health care
to notify the person of your location or general condition or payment
related to your health care. In addition, we may disclose your protected
health information to a public or private entity authorized by law to
assist in a disaster relief effort. If you are unable to agree or object
to such a disclosure we may disclose such information if we determine
that it is in your best interest based on our professional judgment
or if we reasonably infer that you would not object.
- Public
Health Activities - We may disclose your protected health information
to a public health authority that is authorized by law to collect or
receive such information, such as for the purpose of preventing or controlling
disease, injury, or disability; reporting births, deaths or other vital
statistics; reporting child abuse or neglect; notifying individuals
of recalls of products they may be using; notifying a person who may
have been exposed to a disease or may be at risk of contracting or spreading
a disease or condition.
- Health
Oversight Activities - We may disclose your protected health information
to a health oversight agency for activities authorized by law, such
as audits, investigations, inspections, accreditation, licensure and
disciplinary actions.
- Judicial
and Administrative Proceedings - If you are involved in a lawsuit
or a dispute, we may disclose your protected health information in response
to your authorization or a court or administrative order. We may also
disclose your protected health information in response to a subpoena,
discovery request, or other lawful process if such disclosure is permitted
by law.
- Law
Enforcement - We may disclose your protected health information
for certain law enforcement purposes if permitted or required by law.
For example, to report gunshot wounds; to report emergencies or suspicious
deaths; to comply with a court order, warrant, or similar legal process;
or to answer certain requests for information concerning crimes.
- Coroners,
Medical Examiners, Funeral Directors, Organ Procurement Organizations
- We may release your protected health information to a coroner, medical
examiner, funeral director, or, if you are an organ donor, to an organization
involved in the donation of organs and tissues.
- Research
Purposes - Your protected health information may be used or disclosed
for research purposes, but only if the use and disclosure of your information
has been reviewed and approved by a special Privacy Board or Institutional
Review Board, or if you provide authorization.
- To
Avert a Serious Threat to Health or Safety - We may use and disclose
your protected health information when necessary to prevent a serious
threat to your health or safety or the health or safety of the public
or another person. Any disclosure, however, would be to someone able
to help prevent the threat.
- Military
and National Security - If required by law, if you are a member
of the armed forces, we may use and disclose your protected health information
as required by military command authorities or the Department of Veterans
Affairs. If required by law, we may disclosure your protected health
information to authorized federal officials for the conduct of lawful
intelligence, counter-intelligence, and other national security activities
authorized by law. If required by law, we may disclose your protected
health information to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads
of state or conduct special investigations.
- Workers'
Compensation - We may use or disclose your protected health information
as permitted by laws relating to workers' compensation or related programs.
- Special
Rules Regarding Disclosure of Psychiatric, Substance Abuse and HIV-Related
Information - For disclosures concerning protected health information
relating to care for psychiatric conditions, substance abuse or HIV?related
testing and treatment, special restrictions may apply. For example,
we generally may not disclose this specially protected information in
response to a subpoena, warrant or other legal process unless you sign
a special Authorization or a court orders the disclosure.
- Mental
health information. Certain mental health information may be disclosed
for treatment, payment and health care operations as permitted or required
by law. Otherwise, we will only disclose such information pursuant to
an authorization, court order or as otherwise required by law. For example,
all communications between you and a psychologist, psychiatrist, social
worker and certain therapists and counselors will be privileged and
confidential in accordance with Connecticut and Federal law.
- Substance
abuse treatment information. If you are treated in a specialized
substance abuse program, the confidentiality of alcohol and drug abuse
patient records is protected by Federal law and regulations. Generally,
we may not say to a person outside the program that you attend the program,
or disclose any information identifying you as an alcohol or drug abuser,
unless:
1.
You consent in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical
emergency or to qualified personnel for research, audit, or program
evaluation.
Violation of these Federal laws and regulations by us is a crime.
Suspected violations may be reported to appropriate authorities in
accordance with Federal regulations. Federal law and regulations do
not protect any information about a crime committed by a patient either
at the substance abuse program or against any person who works for
the program or about any threat to commit such a crime. Federal laws
and regulations do not protect any information about suspected child
abuse or neglect from being reported under State law to appropriate
State or local authorities.
- HIV-related
information. We may disclose HIV?related information as permitted
or required by Connecticut law. For example, your HIV-related information,
if any, may be disclosed without your authorization for treatment purposes,
certain health oversight activities, pursuant to a court order, or in
the event of certain exposures to HIV by personnel of Clifford Beers
Clinic, another person, or a known partner.
- Minors.
We will comply with Connecticut law when using or disclosing protected
health information of minors. For example, if you are an unemancipated
minor consenting to a health care service related to HIV/AIDS, venereal
disease, abortion, outpatient mental health treatment or alcohol/drug
dependence, and you have not requested that another person be treated
as a personal representative, you may have the authority to consent
to the use and disclosure of your health information.
When
We May Not Use or Disclose Your Protected Health Information
Except as described in this Notice, or as permitted by Connecticut or
Federal law, we will not use or disclose your protected health information
without your written authorization.
Your
written authorization will specify particular uses or disclosures that
you choose to allow. Under certain limited circumstances, Clifford Beers
Clinic may condition treatment on the provision of an authorization, such
as for research related to treatment. If you do authorize us to use or
disclose your protected health information for reasons other than treatment,
payment or health care operations, you may revoke your authorization in
writing at any time by contacting Clifford Beers Clinic's Privacy Officer.
If you revoke your authorization, we will no longer use or disclose your
protected health information for the purposes covered by the authorization,
except where we have already relied on the authorization.
Psychotherapy
Notes
A signed authorization or court order is required for any use or disclosure
of psychotherapy notes except to carry out certain treatment, payment,
or health care operations and for use by Clifford Beers Clinic for treatment,
for training programs, or for defense in a legal action.
Marketing
A signed authorization is required for the use or disclosure of your protected
health information for a purpose that encourages you to purchase or use
a product or service except for certain limited circumstances such as
when the marketing communication is face-to-face or when marketing includes
the distribution of a promotional gift of nominal value provided by Clifford
Beers Clinic.
Your
Health Information Rights
You have the following rights with respect to your protected health information.
The following briefly describes how you may exercise these rights.
- Right
to Request Restrictions of Your Protected Health Information - You
have the right to request certain restrictions or limitations on the
protected health information we use or disclose about you. You may request
a restriction or revise a restriction on the use or disclosure of your
protected health information by providing a written request stating
the specific restriction requested. You can obtain a Request for Restriction
form from Clifford Beers Clinic. We are not required to agree to your
requested restriction. If we do agree to accept your requested restriction,
we will comply with your request except as needed to provide you with
emergency treatment. If restricted protected health information is disclosed
to a health care provider for emergency treatment, we will request that
such health care provider not further use or disclose the information.
In addition, you and Clifford Beers Clinic may terminate the restriction
if the other party is notified in writing of the termination. Unless
you agree, the termination of the restriction is only effective with
respect to protected health information created or received after we
have informed you of the termination.
- Right
to Receive Confidential Communications - You have the right to request
a reasonable accommodation regarding how you receive communications
of protected health information. You have the right to request an alternative
means of communication or an alternative location where you would like
to receive communications. You may submit a request in writing to Clifford
Beers Clinic requesting confidential communications. You can obtain
a Request for Confidential Communications form from Clifford Beers Clinic.
- Right
to Access, Inspect and Copy Your Protected Health Information -
You have the right to access, inspect and obtain a copy of your protected
health information that is used to make decisions about your care for
as long as the protected health information is maintained by Clifford
Beers Clinic. To access, inspect and copy your protected health information
that may be used to make decisions about you, you must submit your request
in writing to Clifford Beers Clinic. If you request a copy of the information,
we may charge a fee for the costs of preparing, copying, mailing or
other supplies associated with your request. We may deny, in whole or
in part, your request to access, inspect and copy your protected health
information under certain limited circumstances. If we deny your request,
we will provide you with a written explanation of the reason for the
denial. You may have the right to have this denial reviewed by an independent
health care professional designated by us to act as a reviewing official.
This individual will not have participated in the original decision
to deny your request. You may also have the right to request a review
of our denial of access through a court of law. All requirements, court
costs and attorney's fees associated with a review of denial by a court
are your responsibility. You should seek legal advice if you are interested
in pursuing such rights.
- Right
to Amend Your Protected Health Information - You have the right
to request an amendment to your protected health information for as
long as the information is maintained by or for Clifford Beers Clinic.
Your request must be made in writing to Clifford Beers Clinic and must
state the reason for the requested amendment. You can obtain a Request
for Amendment form from Clifford Beers Clinic. If we deny your request
for amendment, we will give you a written denial including the reasons
for the denial and the right to submit a written statement disagreeing
with the denial. We may rebut your statement of disagreement. If you
do not wish to submit a written statement disagreeing with the denial,
you may request that your request for amendment and your denial be disclosed
with any future disclosure of your relevant information.
- Right
to Receive An Accounting of Disclosures of Protected Health Information
- You have the right to request an accounting of certain disclosures
of your protected health information by Clifford Beers Clinic or by
others on our behalf. To request an accounting of disclosures, you must
submit a request in writing, stating a time period beginning on or after
April 14, 2003 that is within six (6) years from the date of your request.
The first accounting provided within a twelve-month period will be free.
We may charge you a reasonable, cost-based fee for each future request
for an accounting within a single twelve-month period. However, you
will be given the opportunity to withdraw or modify your request for
an accounting of disclosures in order to avoid or reduce the fee.
- Right
to Obtain A Paper Copy of Notice - You have the right to obtain
a paper copy of this Notice, even if you have agreed to receive this
Notice electronically. You may request a copy of this Notice at any
time by contacting Clifford Beers Clinic. In addition, you may obtain
a copy of this Notice at our web site, www.cliffordbeers.org.
- Right
to Complain - You may file a complaint with us or 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. You will not be penalized for filing
a complaint and we will make every reasonable effort to resolve your
complaint with you.
Clifford
Beers Clinic
Shannon Browne, Privacy Officer
93 Edwards Street
New Haven, CT 06511
(203) 772-1270
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