Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

Effective Date: April 14, 2003

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Reliance House, Inc.’s Privacy Officer at (860) 887-6536 ext. 214

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 Reliance House, Inc. may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and/or disclosure of your protected health information. Your “protected health information” is information about you created and received by us that may reasonably identify you. This information 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 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. We may, however, 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.RelianceHouse.org , contact the Reliance House Privacy Officer or ask your Reliance House contact person at your next appointment.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The Reliance House Inc. Intake Director or your Case Manager will ask you to sign a consent form that allows Reliance House Inc. 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 are examples of the types of uses and disclosures of your protected health information that Reliance House is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, rather to clarify the uses of protected health information.

· For Treatment - We may use and disclose your protected health information to provide you with psychosocial/rehabilitative services on an as-needed basis. For example, your protected health information may be used for the purpose of developing a service plan or making a referral to additional services or programming. 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 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 payer. For example, when we bill your insurance provider, we may have to notify them of the services you receive from us in order to receive payment for those services.
· For Health Care Operations - We may use and disclose your health information as necessary for operations of Reliance House, Inc. 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 Reliance House. For example, members of the Reliance House Quality Assurance Committee may use information in your record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the services we provide.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR WRITTEN AUTHORIZATION

Under the Privacy Regulations, we may make the following uses and disclosures without obtaining a written Authorization from you:

· Business Associates – There may be some services provided in our organization through contracts with business associates, such as a billing services, legal or accounting consultants, or clinical services. 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.
· Treatment Alternatives and Other Health-Related Benefits and Services – We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.
· 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 or payment related to your health care.
· Disaster Relief – 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 or deaths, 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, and licensure.
· Judicial and Administrative Proceedings – We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process.
· Law Enforcement – We may disclose your protected health information for certain law enforcement purposes if permitted or required by law. Examples include filing reports required by law or reporting emergencies or suspicious deaths; complying with a court order, warrant, or other legal process; identifying or locating a suspect or missing person; or answering 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 – Your protected health information may be used for research purposes, but only if the privacy aspects of the research have been reviewed and approved through the Reliance House Research Policy and Procedure process 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 and safety or the health and safety of the public or another person. Disclosure would, however, be limited to someone able to help lessen or prevent the threat.
· Military and Veterans – 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.
· National Security – 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.
· Inmates/Law Enforcement Custody – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the institution or official for certain purposes including your own health and safety as well as that of others.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR ALL OTHER DISCLOSURES OF YOUR HEALTH INFORMATION

We will obtain your written authorization (an "Authorization") prior to making any use or disclosure other than those described above. A written Authorization is designed to inform you of a specific use or disclosure, other than those set forth above, that we plan to make of your health information. The Authorization describes the particular health information to be used or disclosed and the purpose of the use or disclosure. Where applicable, the written Authorization will also specify the name of the person to whom we are disclosing the health information. The Authorization will also contain an expiration date or event. You may revoke a written Authorization previously given by you at any time but you must do so in writing. If you revoke your Authorization, we will no longer use or disclose your health information for the purposes specified in that Authorization except where we have already taken actions in reliance on your Authorization.

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.
· Psychiatric 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.
· Substance Abuse Treatment Information - If you are treated in a specialized substance abuse program, your permission will be needed for certain disclosures, not including emergencies, certain reporting requirements and other disclosures specifically allowed under Federal law.
· HIV-Related Information - We will disclose HIV-related information as permitted or required by Connecticut law. For example your HIV-related protected health information, if any, may be disclosed in the event of a significant exposure to HIV-infection to personnel or members of Reliance House or a known partner. Any use and disclosure for such purposes will be limited to someone able to reduce the outcome of the exposure and limited in accordance with Connecticut and Federal law.

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, Reliance House may condition services on the provision of an authorization, such as research related to treatment. If you do authorize us to use or disclose your protected health information for reasons other than that treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting Reliance House’s Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the purpose covered by the authorization, except where we have already relied on the authorization.

YOUR HEALTH INFORMATION RIGHTS

You have the following rights with respect to your protected health information:

· Right to Request Restrictions of Your Protected Health Information - You have the right to request that we restrict the way we use or disclose your health information for treatment, payment or health care operations. However, we are not required to agree to the restriction. If we do agree to a restriction, we will honor that restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your treatment.
· 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.
· 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 created and maintained by Reliance House Inc. Requests may be submitted to the Reliance House Privacy Officer. 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 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 created and maintained by Reliance House Inc. for as long as the information is maintained by or for Reliance House, Inc. Your request must be made in writing to the Reliance House Privacy Officer and must state the reason for the requested amendment. 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 Reliance House, Inc. or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning 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.
· 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 Reliance House, Inc. In addition, you may obtain a copy of this Notice at our web site, www.RelianceHouse.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. You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you. To file a complaint, please contact:
Reliance House Privacy Officer
40 Broadway, Norwich , CT 06360
860-887-6536 x214