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
Bridges..A Community Support System, Inc.
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 Bridges.
Bridges, A Community Support System, Inc.
Terri Eblen, Privacy Officer
949 Bridgeport Avenue, Milford, CT 06460
203-878-6365 ext. 311
Notice of Privacy Practices
Effective Date: April 14, 2003 and Revised February 17, 2010
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.bridgesmilford.org, contact Bridges or ask at your
next appointment.
How We May Use or Disclose Your Protected Health Information
Bridges will ask you to sign a consent form that allows Bridges
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, Bridges 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 the extent practical to accomplish the intended purpose
of any use, disclosure or request for protected health information in a "limited data set" 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 treatment and related services.
Your protected health information may be used in emergency situations in order to provide other providers assistance in support of a crisis stabilization plan. 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 Bridges 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
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 Bridges, 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 Bridges.
- 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 administratively, physically and technically safeguard your information. In addition, we require business associates to uphold same policies and procedures related to breaches as we do and business associates are subject to same civil and criminal penalties applied to Bridges.
- Appointment Reminders - We
may use and disclose protected health information to contact
you as a reminder that you have an appointment.
- 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 Bridges 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 Bridges. A description of how to opt out of receiving
any further fundraising communications will be included with
any fundraising materials you receive from Bridges. 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 and preferably sign a release for, 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. No information will be given
over the telephone, unless we have written authorization to do
so, and the person called has verified who they are.
- 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.
- 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 een reviewed and approved
by Bridges Human Subjects Research Review Committee, 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/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 member of your treatment team will be privileged
and confidential in accordance with CT 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:
- You
consent in writing;
- The disclosure is allowed by a court
order; or
- 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/regulations by us is a crime. Suspected
violations may be reported to appropriate authorities
in accordance with Federal regulations. Federal law/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/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/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 Bridges, another person, or a
known partner.
- Minors. We will comply with CT 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, outpatient mental health treatment or alcohol/drug
dependence, 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,
Bridges 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
Bridges’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
Bridges 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 Bridges. If Bridges chose to send out a marketing communication, it shall not accept paymant directly or indirectly.
Your Health Information Rights -You have the following rights
with respect to your protected health information. The following
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/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. Bridges cannot use protected health information of payment or health care operations to a health plan if the protected health information subject to restriction pertains solely to a service paid out-of-pocket in full. You
can obtain a Request for Restriction form from Bridges. 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 Bridges 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 Bridges requesting confidential
communications. You can obtain a Request for Confidential Communications
form from Bridges.
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 Bridges. 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 Bridges. 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. You have the right to access in electronic format the current extent of your electronic health record and the fee charged is capped at cost of labor to provide. 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 Bridges.
Your request must be made in writing to Bridges and must state
the reason for the requested amendment. You can obtain a Request
for Amendment form from Bridges. 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/Breaches
of Unsecured Protected Health Information - You have the right to be notified by us or by one of our business associates in the event that unsecured protected health information is breached. In addition, you have the right to request an accounting of certain
disclosures of your protected health information by Bridges 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 Bridges. In addition, you may
obtain a copy of this Notice at our web site, www.bridgesmilford.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.
Terri Eblen, Privacy Officer, Bridges..A Community Support System,
Inc, 949 Bridgeport Avenue, Milford, CT 06460 203-878-6365 ext.
311
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