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.
EFFECTIVE DATE: April 14, 2003
Your Privacy is Important
The Fairfax-Falls Church Community Services Board (CSB)
understands your privacy is important. We are required by law to
maintain the privacy of protected health information and to provide
you with notice of our legal duties and privacy practices with
respect to protected health information. We are required to abide
by the terms of this notice. We will handle this information only
as allowed by federal/ state law and agency policy, adhering to the
most stringent law that protects your health information.
If at any time you believe your privacy rights have been violated,
you may verbally or in writing contact:
-
Your therapist/case manager
-
Your therapist's/case manager's supervisor
-
The Quality Assurance Coordinator for Mental Health (MH), Mental
Retardation (MR) or Alcohol and Drug Services (ADS)
-
Fairfax County's HIPAA Compliance Manager
-
State Human Right's Advocate
-
Secretary of Health and Human Services of the Federal Government,
Office of Civil Rights
Addresses and phone numbers to use are listed at the end of this
notice. You will not suffer any change in services or retaliation
for filing a complaint.
Each time you receive services from us, the provider makes a
record of the visit. Typically, this record contains your
assessment, service plan, progress notes, diagnoses, treatment, and
plan for future care or treatment.
Your Federally-Defined Rights under 45 C.F.R. Parts 160 and 164
(HIPAA Privacy Standards), and under The Commonwealth of Virginia's
Administrative Code, Title 12, Sections 35-115-80 and 35-115-90
(Human Rights).
There are several rights concerning your protected health
information that we want you to be aware of:
-
You have the right to inspect or to request copies of your
medical records. This process will be kept confidential. This
right is not absolute. In certain situations, such as if access
would cause harm, we can deny access. You must make this request
in writing to your Primary Therapist/Case Manager or his/her
Supervisor. If denied access, you will receive a timely, written
notice of the decision and reason. A copy of this request and
written reply becomes a part of your record.
-
You have the right to request amendment of your medical records
if you believe information in the records is inaccurate or
incomplete. You must make this request in writing to your Primary
Therapist/Case Manager or his/her supervisor. We may deny the
request but you will be provided with a written explanation of
the denial.
-
You have the right to receive an accounting of the CSB's
disclosures of your protected health information that were not
for the purpose of treatment, payment, health care operations, or
that were not otherwise authorized by you. You also have the
right to be given the names of anyone, other than employees of
the agency, who received information about you from the CSB.
-
You have the right to request from your Primary Therapist/Case
Manager a restriction with regards to the use or disclosure of
your protected health information. This request will be given
serious consideration by the CSB staff and you will be informed
promptly whether we will be able to honor the requested
restriction and still offer effective services, receive payment
and maintain health care operations. Legally we are not required
to agree to any restrictions you request, but if we do agree, we
are bound by that agreement except under certain emergency
circumstances.
-
You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. Such
requests must be made in writing to your Primary Therapist/Case
Manager. We will agree to all reasonable requests.
-
You have the right to obtain a paper copy of this Notice of
Privacy Practices at any time upon request.
Use and Disclosure of Your Information
Upon signing the agency's Consent to Treatment/ Service form, you
are allowing us to use and disclose necessary information about you
within the agency and with business associates in order to provide
treatment/service, receive payment of provided treatment/service,
and conduct our day to day health care operations.
Examples:
-
In order to effectively provide treatment/service, your
Primary Therapist/Case Manager may consult with various service
providers within the CSB. During those consultations health
information about you may be shared.
-
In order to receive payment of services provided, your health
information may be sent to those companies or groups responsible
for payment coverage, and a monthly bill is sent to the
Responsible Party identified by you and noted on the financial
form.
-
In day-to-day health care operations, trained staff may handle
your client record in order to have the record assembled,
available for review by the Primary Therapist/Case Manager, or
for filing of documentation. Certain data elements are entered
into our computer system that processes most billing, and for
state statistical reporting to the Department of Mental Health,
Mental Retardation and Substance Abuse Services (DMHMRSAS). As a
part of our continuous quality improvement efforts to provide the
most effective services, your record may be reviewed by
professional staff to assure accuracy, completeness and
organization. Records may also be reviewed during licensing
reviews by DMHMRSAS and accreditation surveys by the Commission
on Accreditation of Rehabilitation Facilities (CARF).
Enhancing Your Healthcare
Some CSB programs provide the following support to enhance your
overall health care and may contact you to provide:
-
Appointment reminders by call or letter
-
Information about treatment alternatives
-
Information about health-related benefits and services that may
be of interest to you.
The Community Food Security (CFS) afternoon snack programs are
required by the USDA to maintain a log of those participating.
Individuals Involved in Your Care or Payment for That Care
Unless you object, we may release medical information about you to
a friend or family member who is involved in your care. We may also
give information to someone who helps pay for your care.
Specific Circumstances for Disclosure
This agency is also allowed by Federal and State law in certain
circumstances to disclose specific health information about you.
These specific circumstances are:
-
As required by law (ex: reports required for public health
purposes, such as reporting certain contagious diseases)
-
Judicial and Administrative proceedings (ex: Order from a court
or administrative tribunal, or legal counsel to the agency, or
Inspector General)
-
Law Enforcement purposes (ex: reporting of gun shot wounds;
limited information requested about suspects, fugitives, material
witnesses, missing persons; criminal conduct on premises)
-
To avert a serious threat to Health and Safety of another person
(ex: in response to a specific threat made by the person served
to harm another)
-
Children or incapacitated adults who are victims of abuse,
neglect or exploitation
-
Specialized Government functions
-
Military Services (ex: in response to appropriate military
command to assure the proper execution of the military
mission)
National Security and Intelligence activities (ex: in relation
to protective services to the President of the United States)
-
State Department (ex: medical suitability for the purpose of
security clearance)
-
Correctional Facilities (ex: to correctional facility about an
inmate)
-
Workers Compensation to facilitate processing and payment
-
Coroners and Medical Examiners for identification of a deceased
person or to determine cause of death
-
To the Federal Department of Health and Human Services in
connection with an investigation of us for compliance with
federal regulations.
Other Uses and Disclosures of Your Information by Authorization
Only
We are required to get your authorization to use or disclose your
protected health information for any reason other than for
treatment/services, payment, or health care operations, and those
specific circumstances outlined previously. We use an Authorization
to Use/Disclose form that specifically states what information will
be given to whom, for what purpose, and is signed by you or your
legal representative. You have the ability to revoke the signed
authorization at any time by a written statement except to the
extent that we have acted on the authorization.
Changes to Privacy Practices
The CSB reserves the right to change its privacy policy and any of
its privacy practices at any time, as allowed by Federal and State
law and to make the change effective for all protected health
information that we maintain.
A Revised Notice of Privacy Practices will be posted at all
service sites, made available upon request by mailing or discussion
with a CSB representative, electronically on the CSB's Web page (www.fairfaxcounty.gov/csb) by clicking Notice of
Privacy Practices, or a combination of the three.
Additional Information & Complaints
For additional information concerning our Privacy Practices or the
Federal and State laws pertaining to privacy or to file a complaint
please contact one of the following:
-
Your Primary Therapist/Case Manager
-
Your Primary Therapist/Case Manager's Immediate Supervisor
-
Your Program's Quality Assurance Coordinator
Mental Health Services
Northwest Mental Health Center
1850 Cameron Glen Drive
Reston, VA 20190
Phone: 703-481-4115
TTY: 703-481-4110
Alcohol & Drug Services
3900 Jermantown Road; Suite 200
Fairfax, VA 22030
Phone: 703-934-8745
TTY: 703-322-9080
Mental Retardation Services
12011 Government Center Parkway; Suite 300
Fairfax, VA 22035
Phone: 703-324-4426
TTY: 703-324-4495
-
Fairfax County's HIPAA Compliance Manager
Fairfax County Government Center
12000 Government Center Parkway; Suite 527
Fairfax, VA 22035
Phone: 703-324-4136
TTY: 703-968-0217
-
State Human Rights Regional Advocate
Northern Virginia Training Center
9901 Braddock Rd
Fairfax, VA 22032
Phone: 703-323-2098
-
Office of Civil Rights
Department of Health and Human Services
150 S. Independence Mall West; Suite 372
Public Ledger Building
Philadelphia, PA 19106-9111
Main line: 215-861-4441
Hotline: 800-368-1019
Fax: 215-861-4431
TDD: 215-861-4440
Note to TTY Users: If direct dial number is not provided,
please use the Virginia Relay Center (711) to contact any of the
offices above.
|
