Effective Date: April 1, 2003
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.
We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of Inspire. If you have any questions about this notice or would like further information, please contact the Privacy Officer at (845) 294-8806.
WHO WILL FOLLOW THIS NOTICE
All people who work for Inspire in our service programs and in our administrative offices will follow this notice. This includes employees, persons Inspire contracts with (contractors) who are authorized to enter information in your clinical record or need to review your record to provide services to you, and volunteers that Inspire allows to assist you.
PERMISSIONS DESCRIBED IN THIS NOTICE
This notice will explain the different types of permission we will obtain from you before we use or disclose your health information for a variety of purposes. The three types of permissions referred to in this notice are:
1. A “general written consent,” which we must obtain from you in order to use and disclose your health information in order to treat you, obtain payment for that treatment, and conduct our business operations. We must obtain this general written consent the first time we provide you with treatment or services. This general written consent is a broad permission that does not have to be repeated we will ask you to renew annually.
2. An “opportunity to object,” which we must provide to you before we may use or disclose your health information for certain purposes. In these situations, you will have an opportunity to object to the use or disclosure of your health information in person, over the phone, or in writing.
3. A “written authorization,” which will provide you with detailed information about the persons who may receive your health information and the specific purposes for which your health information may be used or disclosed. We are only permitted to use and disclose your health information described on the written authorization in ways that are explained on the written authorization form you have signed. A written authorization will have an expiration date.
WHAT INFORMATION IS PROTECTED
We are committed to protecting the privacy of information we gather about you
while providing services. Some examples of protected health information are:
• Information indicating that you are receiving treatment or other health-related
services from Inspire;
• Information about your condition;
• Information about services you have received or may receive in the future;
• Information about your health care benefits under an insurance plan;
when combined with :
• Demographic information (such as your name, address, or insurance status);
• Unique numbers that may identify you (such as your social security number,
your phone number, or your driver’s license number); and
• Other types of information that may identify who you are.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
1. Treatment, Payment and Business Operations
With your general consent, we may use your health information in order to treat you, obtain payment for that treatment, and run our business operations. We may also disclose your health information for payment activities and business operations of another health care provider or payor.
• Treatment: Inspire may share your health/clinical information with
among its own providers and mangers in order to serve you, and we may use that
information to treat you. Inspire will not share information for treatment purposes
outside its own providers without your authorization.
• Payment: Inspire may use your health/clinical information so that we
can bill and collect payment from you, a third party, an insurance company,
Medicare or Medicaid, or other payors. For example, we may need to disclose
your health/clinical information to receive prior approval and payment of services
you may need from your insurance company.
• Business Operations: Inspire may use health/clinical information for
administrative operations. For example, we may use health/clinical information
for quality improvement to review our treatment and services and to evaluate
the performance of our staff in caring for you. We may disclose health/clinical
information to our business associates who need access to the information to
perform administrative or professional services on our behalf.
• Appointment Reminders: We may contact you with a reminder that you have
an appointment for treatment or services at one of our programs.
• Fundraising: We may use demographic information about you, including
information about your age and gender, and where you live, in order to contact
you to raise money to help us operate. Such information would not disclose individualized
information. We would not disclose individualized information for public relations,
funding, or grant purposes without specific authorization from you.
• Business Associates: We may disclose your health/clinical information
to contractors, agents and other business associates who need the information
in order to assist us with obtaining payment or carrying out our business operations.
For example, we may share your health information with a billing company that
helps us to obtain payment from your insurance company. If we do disclose your
health information to a business associate, we will have a written contract
to ensure that our business associate also protects the privacy of your health
information.
We can do all of these things if you have signed a general written consent form. Your general written consent will be in effect indefinitely. You may revoke your general written consent at any time, except to the extent that we have already relied on it. For example, if we provide you with treatment before you revoke your general written consent, we may still share your health information with your insurance company in order to obtain payment for that treatment. To revoke your general written consent, please write to the Privacy Officer at Inspire, 2 Fletcher Street, Goshen, NY 10924.
2. Family, Friends and Assistance
If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative or another person responsible for your care if we are unable to reach you.
If you do not object, we may share your health information with disaster relief organizations that need to notify your family about your condition and locations should a disaster occur.
3. Emergencies or Public Need
We may use your health information, and share it with others, in order to treat you in an emergency or to meet important public needs. We will not be required to obtain your consent before using or disclosing your information for these reasons. We will, however, obtain your written authorization for, or provide you with an opportunity to object to, the use and disclosure of your health information in these situations when state law specifically requires that we do so.
• Emergencies: We may use or disclose your health information if you
need emergency treatment or if we are required by law to treat you but are unable
to obtain your written consent. If this happens, we will try to obtain your
general written consent as soon as we reasonably can.
• As Required by Law: We may use or disclose your health information if
we are required by law to do so. We also will notify you of these uses and disclosures
if notice is required by law.
• Public Health: We may use or disclose your health information for public
health reasons, including prevention and control of disease, injury or disability;
child abuse or neglect; reactions to medication or problems with products; and
to notify people who may have been exposed to a disease or are at risk of spreading
disease.
• Domestic Violence and Abuse: We may use or disclose your health information
to report domestic violence and adult abuse or neglect to government authorities
if you agree or if necessary to prevent serious harm.
• Health Oversight: We may use or disclose your health information for
health oversight activities, including audits, investigations, surveys, inspections
and licensure. These activities are necessary for government to monitor the
health care system, government programs, and compliance with civil rights law.
• Judicial and Administrative Proceedings: We may use or disclose your
health information for judicial and administrative proceedings, including hearings
and disputes. If you are involved in a court or administrative proceeding we
may disclose your health/clinical information if the judge or presiding officer
orders us to share the information.
• Law Enforcement: We may use or disclose your health/clinical information
in response to a subpoena, or other legal process; to identify a suspect, witness,
or missing person; regarding a victim of a crime, a death or criminal conduct
at the facility; and in emergency circumstances to report a crime.
• Coroners, Medical Examiners, and Funeral Directors: We may be required
to disclose your health information to a coroner, medical examiner or funeral
director.
• Organ Donations: We may use or disclose your health information to organ
and tissue procurement organizations so that these organizations may investigate
whether donation or transplantation is possible under applicable laws.
• Workers Compensation: We may disclose your health information for workers’
compensation or similar programs that provide benefits for work-related injuries.
• Research: When you have agreed to participate in a research project,
we may use or disclose your health information. Under no circumstances do we
allow researchers to use your name or identity publicly. In most cases, we will
ask for your written authorization before using your health information or sharing
it with others in order to conduct research.
• Serious and Imminent Threat: We may use your health information or share
it with others when necessary to prevent a serious and imminent threat to your
health and safety, or the health and safety of another person or the public.
We may disclose your information to law enforcement officers if you tell us
that you participated in a violent crime that may have caused serious physical
harm to another person, unless you admitted that fact while in counseling. We
may disclose your information if we determine that you escaped from lawful custody,
such as a prison or mental health institution.
• National Security: We may disclose your health information to authorized
federal officials for intelligence and other national security activities authorized
by law, or to provide protective services to the President or other important
officials.
• Military and Veterans: If you are in the Armed Forces, we may disclose
health information about you to appropriate military command authorities for
activities they deem necessary to carry out their military mission.
• Inmates and Correctional Institutions: If you are an inmate or detained
by law, we may disclose your health information if necessary to provide you
with health care, protect your health and safety or that of others, or for the
safety of the correctional institution.
• Government Agencies: We may disclose your health information to governmental
agencies that administer public benefits if necessary to coordinate the covered
functions of the programs.
4. Completely De-identified or Partially De-identified Information
We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is “completely de-identified.” We may also use and disclose “partially de-identified” health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number).
5. Incidental Disclosures
While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment visit, other patients in the area may see you or overhear discussion of your health information.
6. Disclosures that Require Authorization
For all other types of uses and disclosures not described in this Notice, Inspire will use or disclose health/clinical information only with your written authorization, signed by you or an authorized personal representative, that states who may receive the information, what information is to be shared, the purpose of the use or disclosure, and an expiration for the authorization. Written authorizations are always required for use and disclosure of psychotherapy notes and for marketing purposes. Inspire will require your authorization to disclose your information to another provider.
You may revoke your authorization in writing at any time. If you revoke your authorization we will no longer use or disclose your health/clinical information for the reasons stated in your authorization. We cannot, however, take back disclosures we made before you revoked your authorization. We must retain health/clinical information that indicates the services we have provided for you.
YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION
You have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters.
1. Right to Inspect and Copy Records
You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes medical and billing records. This right does not include psychotherapy notes, records regarding incident reports and investigations, copyrighted test forms, and information compiled for use in court or administrative proceedings. Your request to review your information must be in writing. We will respond to your request in 10 days.
If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. The standard fee is $0.75 per page.
In some circumstances, we may deny your request to see your health/clinical information. We will provide a summary of the information instead, with a written reason for the denial. You have the right to request a review of the denial, and to file a complaint about the denial.
2. Right to Amend Records
If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our records. Requests for amendment must be in writing, and include the reasons why you think we should make the amendment. If we approve the request for amendment, we will change the health information, inform you of that action, and tell others that need to know about the change in information. If we deny your request for amendment, we will give a written explanation.
3. Right to an Accounting of Disclosures
After April 14, 2003, you have the right to request an “accounting of disclosures” which identifies certain other persons or organizations to whom we have disclosed your health information in accordance with applicable law and the protection named in this Privacy Notice. An accounting of disclosures does not describe the ways your health information has been shared within and between Inspire staff, as long as all other protections described in this Notice have been followed.
An accounting of disclosures also does not include information about the following:
• Disclosures we made to you or to your personal representative;
• Disclosures we made pursuant to your written authorization;
• Disclosures we made for treatment, payment or business operations;
• Disclosures made to your friends and family involved in your care or
payment for your care;
• Disclosures that were incidental to permissible uses and disclosures
of your health information;
• Disclosures of limited portions of your health information that do not
directly identify you and done for the purposes of research, public health or
our business operations;
• Disclosures made to federal officials for national security and intelligence
activities;
• Disclosures about inmates to correctional institutions or law enforcement
officers;
• Disclosures made before April 14, 2003.
To request an accounting of disclosures, please write to the Privacy Officer. Your request must state a time period within the past six years (but after April 14, 2003) for the disclosures you want us to include.
Ordinarily we will respond to your request for an accounting within 30 days. If we need additional time, we will notify you in writing about the reason for the delay and the date when you can expect to receive your accounting, unless a law enforcement official or government agency has asked us to delay the accounting.
4. Right to Request Additional Privacy Protection
You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our business operations. You may also request that we limit how we disclose your information about you to your family or friends involved in your care. To request restrictions, please write to the Privacy Officer. You request should include the following:
1. What information you want to limit;
2. Whether you want to limit how we use the information, how we share the information
with others, or both;
3. To whom you want the limits to apply.
We will consider your request, but are not legally bound to agree to the restriction. If we agree to any restrictions to our use and disclosure of your information, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses and disclosures that are required by law.
5. Right to Request Confidential Communication
You have the right to request that we communicate with you in a way that will help keep your information confidential. For example, you may ask that we contact you at home instead of at work. To request more confidential communications, please write to the Privacy Officer. We will not ask you the reason for your request, and we will try to accommodate reasonable requests. Please specify in your request how and where you wish to be contacted.
6. Right to a Copy of this Notice
You have the right to receive a paper copy of this Notice. You may ask us to provide you with another copy when you visit, or you may obtain one from our Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make changes to terms described in this notice and to make the new notice terms effective to all health/clinical information that we maintain. We will post any new notice with the effective date in our facilities. We will offer you a copy of any revised notice at your next scheduled visit.
COMPLAINTS
If you believe your privacy rights have been violated, you may do one of the following:
? You may file a complaint with the Privacy Officer at Inspire at 2 Fletcher Street, Goshen, NY 10924, (845) 294-8806.
? You may contact the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington DC, 20201, (877) 696-6775.
? You may file a grievance with the Office of Civil Rights by calling 866-OCR-PRIV, or (866) 627-7748, or (886) 788-4989 (TTY).
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
THIS NOTICE REVISED MARCH 31, 2004.