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 (http://fairfaxcounty.gov/csb/homepage.htm)
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
