Notice of Privacy Practices
Rehabilitation Associates, Inc.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
Please Review This Carefully
If you have any questions about this notice, please call: Kelly Dellapiano, Privacy Officer (203) 384-8681
The effective date of this Privacy Notice is August 1st, 2012
At Rehabilitation Associates, Inc. we respect the privacy and confidentiality of your health information. This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your medical/health information and how you can get access to this information. This Notice applies to uses and disclosures we may make of all your health information whether created or received by us.
This Notice of Privacy Practices applies to the Rehabilitation Associates, Inc. facilities located at the following premises:
1931 Black Rock Turnpike- Fairfield, CT 06825
2900 Main Street-Stratford, CT 06614
555 Bridgeport Avenue-Shelton, CT 06484
680 Boston Post Road- Milford, CT 06460
728 Post Road East- Westport, CT 06880
I. OUR RESPONSIBILITIES TO YOU
We are required by law to:
1. Maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices.
2. Comply with the terms of our Notice currently in effect. We reserve the right to change our practices and to make the new provisions effective for all health information we maintain, including both health information we already have and health information we create or receive in the future. Should we make material changes, we will make the revised Notice available to you by posting it in the waiting room of our offices and on our website.
II. HOW WE WILL USE AND DISCLOSE YOUR HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We may use and disclose your health information for purposes of treatment, payment, and health care operations as described below:
1. For Treatment. Your health information may be used by staff members or disclosed to other healthcare professionals for the purpose of evaluating and treating the condition for which your physician referred you, and for coordinating your care. For example, we would disclose your health information, as necessary, to a home health agency that provides care to you. In addition, we may disclose your health information to a physician or other health care provider (e.g., an orthotist) who, at either your or your physician’s request, has become involved in your care. We may also disclose your protected health information in an emergency treatment situation.
2. For Payment. We may use and disclose your health information so that we can bill and receive payment for the treatment and services you receive. For billing and payment purposes, we may disclose your health information to an insurance or managed care company, Medicare, Medicaid, Workers’ Compensation or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request approval for a proposed treatment or service.
3. For Health Care Operations. We may use and disclose your health information, as necessary, for our internal operations, such as for general administration activities and to monitor the quality of care you receive with us. For example, we may use your health information for education and training of our students, interns and staff, as well as planning for services. We may also use your health information to review and evaluate the success of our outcomes. In addition, we may use a “sign in” sheet at the front desk, where you will be asked to sign your name and the time you arrived at our office. Your therapist/therapy aide may call you by name in the waiting room when the therapist is ready to see you . We may also leave a brief message for you at the number you have provided to our office. We may also use a mail courier service to transport PHI from one location to another. In addition, we may use your email address to communicate with you.
III. OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR WRITTEN AUTHORIZATION
1. As Required by Law. We may disclose your health information when required by law to do so. We will disclose information about you when required to do so by federal, state, or local law, or in response to a valid subpoena. By law we will disclose information to your employer if you are involved in a work related injury or illness or for workplace surveillance. We may also release your health information to authorized federal officials for lawful intelligence.
2. Persons Involved in Your Care or Payment for Your Care. Unless you object, we may disclose health information about you to a family member, close personal friend, or other person you identify who is involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in arranging payment for your care.
3. Public Health Activities. We may disclose your health information for public health activities.
4. Reporting Victims of Abuse and/or Neglect. We are required by law to report cases of suspected abuse or neglect and in doing so we may disclose your protected health information to a public health authority that is authorized by law to receive reports of child/elder abuse or neglect. In this case, the report will be made consistent with the requirements of applicable federal and state laws.
5. Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. A health oversight agency is a state or federal agency that oversees the health care system. Some of these activities may include audits, investigations, inspections, and licensure actions.
6. Judicial and Administrative Proceedings. We may disclose your health information in response to a court or administrative order.
7. Law Enforcement. We may disclose your health information for certain law enforcement purposes including, for example, to file reports required by law or to report emergencies or suspicious deaths; to comply with a court order, warrant, or other legal process; to identify or locate a suspect or missing person; or to answer certain requests for information concerning crimes.
8. To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person, we may use or disclose your health information to someone able to help lessen or prevent the threatened harm.
9. Military and Veterans. If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may also use and disclose health information about you if you are a member of a foreign military, as required by the appropriate foreign military authority.
10. National Security and Intelligence Activities; Protective Services for the President and Others. We may disclose health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.
11. 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.
12. Disaster Relief. We may disclose health information about you to an organization assisting in a disaster relief effort.
13. Treatment Alternatives and 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.
14. Business Associates. We may disclose your health information with third party “business associates” that perform various activities (e.g. billing) for the practice. Whenever an arrangement between our offices and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
IV. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR ALL OTHER USES OR DISCLOSURES OF YOUR HEALTH INFORMATION
1. We will obtain your written Authorization prior to making any use or disclosure other than those described above.
2. A written Authorization is required when you or another party requests access to your protected 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.
3. You may revoke a written authorization previously given by you at any time by completing the appropriate form 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.
V. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding your health information:
1. Right to Request Restrictions. 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.
2. Right to Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.
3. Right of Access to Personal Health Information. You have the right to inspect and, upon written request, obtain a copy of your health information except under certain limited circumstances. Under Connecticut law, if Rehabilitation Associates, Inc. makes a copy of your medical record, we will not charge more than 65 cents per page.
We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to health information, in some cases you will have a right to request review of the denial. This review would be performed by a licensed health care professional designated by Rehabilitation Associates, Inc. who did not participate in the decision to deny access.
4. Right to Request Amendment. You have the right to request that we amend your health information. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information: (a) was not created by us, unless you provide reasonable information that the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by us; or (c) is information to which you have a right of access; or (d) is already accurate and complete, as determined by us.
If we deny your request for amendment, we will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your letter of disagreement will be attached to your medical record.
5. Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your health information. This is a listing of disclosures made by us or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions, such as those disclosures made pursuant to a written Authorization which has been signed by you.
You must submit your request in writing and you must state the time period for which you would like the accounting. The accounting will include the disclosure date; the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; and a brief statement of the purpose of the disclosure. The first accounting provided within a 12 month period will be free; for further requests, we may charge you our costs for completing the accounting.
6. Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice. You may request a copy of this Notice at any time. Forms may be obtained by contacting the Office Manager at any of our offices.
VI. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE, AND HIV-RELATED INFORMATION
For disclosures concerning health information relating to care for psychiatric conditions, substance abuse, or HIV-related information, special restrictions apply. For example, we do not disclose this specially protected information unless you sign a special authorization or a court orders the disclosure. A general release of your health information will not be sufficient for purposes of disclosing psychiatric, substance abuse, or HIV-related information.
1. Psychiatric information. We will not disclose records relating to the diagnosis or treatment of your mental health condition without a specific written authorization or as required or permitted by law.
2. HIV-related information. HIV-related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written Authorization. As required by Connecticut law, if we make a lawful disclosure of HIV-related information, we will enclose a statement that notifies the recipient of the information that they are prohibited from further disclosing the information.
3. Substance abuse treatment. If you are treated in a specialized substance abuse program, information which could identify you as an alcohol or drug-dependent patient will not be disclosed without your specific authorization except for purposes of treatment, payment, or where specifically required or allowed under state or federal law.
1. If you would like to submit a comment or complaint about our privacy practices or if you believe that your privacy rights have been violated you may call the matter to our attention by sending a letter describing the cause of your concern to our Privacy Officer. You will not be penalized or otherwise retaliated against for filing a complaint.
2. If you believe that your privacy rights have been violated, you may file a complaint in writing with us or with the Office of Civil Rights in the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W. Room 509 F, HHH Building, Washington D.C. 20201.
CONTACT PERSON: The name and address of the person you can contact for further information concerning our privacy practices is:
Kelly Dellapiano, Privacy Officer
Rehabilitation Associates, Inc.
1931 Black Rock Tpke.
Fairfield, CT 06825