Privacy Notice
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: 04/14/03
Central Virginia Community Services 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. Any and all information we receive about you will be used only to assist you. 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:
• Agency’s Privacy Officer
• State Advocate
• Secretary of Health and Human Services of the Federal government Addresses and phone numbers to use are listed on the second page of this notice. You will not suffer 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 CFR Parts 160 and 164, HIPAA, and The Commonwealth of Virginia’s Code 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 request access to your medical record in order to inspect, challenge, copy, amend, or correct it. 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 may make this request to your Primary Service Coordinator or the agency’s Consumer Services Coordinator. If denied access, you will receive a timely, written notice of the decision and reason, and a copy of this notice becomes a part of your record.
• You have the right to receive at any time an accounting of the agency’s disclosure of your protected health information not for the purpose of treatment, payment, health care operations, or already authorized by you. You have the right to be given the names of anyone, other than employees of the agency, who received information about you from the agency.
• You have the right to request from your Primary Service Coordinator a restriction with regards to the use or disclosure of your protected health information. This request will be given serious consideration by the Privacy Officer and you will be informed promptly whether we will be able to use the 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.
• You have the right to request an amendment of your protected health information.
• You have the right to receive confidential communications about your protected health information.
• You have the right to request an alternative mode of communication. Legally we are not required to agree to any restrictions you request.
• You have a right to obtain a copy of any authorizations you sign.
• You have the right to obtain a paper copy of this Privacy Notice upon request. Use and Disclosure of Your Information Upon signing the agency’s Consent to Treatment 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 business practices. Examples
In order to effectively provide treatment/service, your Primary Service Coordinator may consult with various service providers within the agency. 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 business practices, trained staff may handle your physical medical record in order to have the record assembled, available for review by the Primary Service Coordinator, 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 (The Department). 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 CARF accreditation surveys, or by The Department. Enhancing Your Healthcare Some agency 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 Child and Family Center snack programs are required by the USDA to maintain a log of those participating Specific Circumstances for Disclosure Although you have the right to give or not give consent to the disclosure of information the agency maintains about you, the agency is allowed by federal and state law in certain circumstances to disclose specific health information about you without your consent, authorization, or opportunity to agree or object. These specific circumstances are: • As required by law (ex: Court-ordered warrant, Virginia Health Information)
• Public Health activities (ex: Communicable 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; witnesses of criminal conduct on premises)
• To avert a serious threat to Health and Safety (ex: in response to a statement made by person served to harm self or another, or substantial property damage)
• 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.
Documentation will be included in your health record of information disclosed without consent to those who are not agency employees, The Department, or other health providers involved in your service plan. 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 treatment/services, payment, or health care operations, and those specific circumstances outlined previously. We use an Authorization for Use or Disclosure of Protected Health Information 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
Central Virginia Community Services reserves the right to change any of its privacy policies and related 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. Revised Privacy Notices will be posted at all service sites, and available upon request by mail or discussion with an agency representative or electronically or a combination of the three. For additional information concerning our Privacy Policy, or the federal and state laws pertaining to privacy, please contact: • Director of Corporate Compliance 434.847.6074
• Consumer Services Coordinator, 434.847.2098
• CVCS Privacy Officer, 2241 Langhorne Road, Lynchburg, VA, 24501, Phone - 434.847.5045
• Regional Advocate, Sherry C. Miles, CVTC, P. O. Box 1098, Lynchburg, VA, 24505, Phone – 434.947.6214
• Secretary of Health and Human Services, Immediate Office of the Secretary, Hubert Humphrey Bldg., 2000 Independence Ave. SW, Washington, DC, 20201, Phone – 202.690.7000
• State Advocate
• Secretary of Health and Human Services of the Federal government Addresses and phone numbers to use are listed on the second page of this notice. You will not suffer 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 CFR Parts 160 and 164, HIPAA, and The Commonwealth of Virginia’s Code 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 request access to your medical record in order to inspect, challenge, copy, amend, or correct it. 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 may make this request to your Primary Service Coordinator or the agency’s Consumer Services Coordinator. If denied access, you will receive a timely, written notice of the decision and reason, and a copy of this notice becomes a part of your record.
• You have the right to receive at any time an accounting of the agency’s disclosure of your protected health information not for the purpose of treatment, payment, health care operations, or already authorized by you. You have the right to be given the names of anyone, other than employees of the agency, who received information about you from the agency.
• You have the right to request from your Primary Service Coordinator a restriction with regards to the use or disclosure of your protected health information. This request will be given serious consideration by the Privacy Officer and you will be informed promptly whether we will be able to use the 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.
• You have the right to request an amendment of your protected health information.
• You have the right to receive confidential communications about your protected health information.
• You have the right to request an alternative mode of communication. Legally we are not required to agree to any restrictions you request.
• You have a right to obtain a copy of any authorizations you sign.
• You have the right to obtain a paper copy of this Privacy Notice upon request. Use and Disclosure of Your Information Upon signing the agency’s Consent to Treatment 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 business practices. Examples
In order to effectively provide treatment/service, your Primary Service Coordinator may consult with various service providers within the agency. 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 business practices, trained staff may handle your physical medical record in order to have the record assembled, available for review by the Primary Service Coordinator, 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 (The Department). 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 CARF accreditation surveys, or by The Department. Enhancing Your Healthcare Some agency 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 Child and Family Center snack programs are required by the USDA to maintain a log of those participating Specific Circumstances for Disclosure Although you have the right to give or not give consent to the disclosure of information the agency maintains about you, the agency is allowed by federal and state law in certain circumstances to disclose specific health information about you without your consent, authorization, or opportunity to agree or object. These specific circumstances are: • As required by law (ex: Court-ordered warrant, Virginia Health Information)
• Public Health activities (ex: Communicable 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; witnesses of criminal conduct on premises)
• To avert a serious threat to Health and Safety (ex: in response to a statement made by person served to harm self or another, or substantial property damage)
• 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.
Documentation will be included in your health record of information disclosed without consent to those who are not agency employees, The Department, or other health providers involved in your service plan. 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 treatment/services, payment, or health care operations, and those specific circumstances outlined previously. We use an Authorization for Use or Disclosure of Protected Health Information 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
Central Virginia Community Services reserves the right to change any of its privacy policies and related 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. Revised Privacy Notices will be posted at all service sites, and available upon request by mail or discussion with an agency representative or electronically or a combination of the three. For additional information concerning our Privacy Policy, or the federal and state laws pertaining to privacy, please contact: • Director of Corporate Compliance 434.847.6074
• Consumer Services Coordinator, 434.847.2098
• CVCS Privacy Officer, 2241 Langhorne Road, Lynchburg, VA, 24501, Phone - 434.847.5045
• Regional Advocate, Sherry C. Miles, CVTC, P. O. Box 1098, Lynchburg, VA, 24505, Phone – 434.947.6214
• Secretary of Health and Human Services, Immediate Office of the Secretary, Hubert Humphrey Bldg., 2000 Independence Ave. SW, Washington, DC, 20201, Phone – 202.690.7000
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