CATHOLIC CHARITIES DIOCESE OF ARLINGTON, INC.

FAMILY SERVICES DEPARTMENT’S

NOTICE OF PRIVACY PRACTICES

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.

COMMITMENT TO PRIVACY

Catholic Charities Diocese of Arlington, Inc. Family Services Department (“CCDA”) is committed to protecting the privacy of your protected health information (“health information”).  Health information is information that identifies you and relates to a physical or mental condition, or to the provision or payment of health services for you.  CCDA also pledges to provide you with certain rights related to your health information.

By this Notice of Privacy Practices (“Notice”), CCDA informs you that it has the following legal obligations under the federal health privacy provisions contained in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the related regulations (“federal health privacy law”): 

·        to maintain the privacy of your health information;

·        to provide you with this Notice of its legal duties and privacy practices with respect to your health information; and

·        to abide by the terms of this Notice.

 

This Notice also informs you how CCDA uses and discloses your health information and explains the rights that you have with regard to your health information maintained by CCDA.

INFORMATION SUBJECT TO THIS NOTICE

 

CCDA collects certain health information about you to help provide health care to you, as well as to fulfill legal requirements.  CCDA collects this information, which identifies you, from forms that you complete, through conversations you may have with CCDA’s administrative staff and health care providers, and from reports and data provided to CCDA by other health care service providers.  The health information CCDA has about you includes, among other things, your name, address, phone number, birth date, employment information, and medical, diagnostic, and other health information.  This is the information that is subject to the privacy practices described in this Notice.

 


SUMMARY OF CCDA’S PRIVACY PRACTICES

CCDA’s Uses and Disclosures of Your Health Information

CCDA uses your health information to provide you with health care, to process and receive payment for health care rendered to you, and to administer its operations.  In some cases, your health information may only be disclosed with your written authorization, while in other instances, your authorization is not required.  For example, CCDA may disclose your health information, without your authorization, to other health care providers for treatment purposes, and to insurers for payment purposes.  CCDA also may disclose your health information, without your authorization, to third parties that assist CCDA in its operations, to certain government and law enforcement agencies, to your family members in limited instances, and to certain other persons.  The details of CCDA’s uses and disclosures of your health information are described below.

Your Rights Related to Your Health Information

The federal health privacy law provides you with certain rights related to your health information.  Specifically, you have the right to:

-           Inspect and/or copy your health information;

-           Request to receive your health information through confidential communications;

-           Request that your health information be amended;

-           Request an accounting of certain disclosures of your health information;

-           Request certain restrictions related to the use and disclosure of your health information;

-           File a complaint with CCDA or the Secretary of the U.S. Department of Health and
            Human Services if you believe that your privacy rights have been violated; and

-           Receive a paper copy of this Notice.

 

These rights and how you may exercise them are detailed below.

Changes in CCDA’s Privacy Policies

CCDA reserves its right to change its privacy practices and revise this Notice as described below.

Contact Information

If you have any questions or concerns about CCDA’s privacy practices, or about this Notice, or you wish to obtain additional information about CCDA’s privacy practices, please contact: 

David Cavanaugh, LCSW, Privacy Officer      

3838 Cathedral Lane, Arlington, VA 22203     

703-841-2531                                                    

 


DETAILED NOTICE OF CCDA’S PRIVACY PRACTICES

CCDA’S USES AND DISCLOSURES

CCDA only uses and discloses your health information as described in this Notice. 

Uses and Disclosures for Treatment, Payment, and Health Care Operations

1.         For Treatment.  CCDA may use and disclose your health information, without your authorization, to a health care provider, such as a hospital or physician, to assist the provider in treating you.  For example, if you see a physician , CCDA may disclose your health information to that physician to help him or her treat you. 

2.         For Payment.  CCDA may use and disclose your health information, without your authorization, so that CCDA can be paid for health care treatment, services and supplies rendered to you. For example, CCDA may need to disclose your health information to an insurer to be reimbursed for services provided to you.

3.         For Health Care Operations.  CCDA may use or disclose your health information, without your authorization, to enable it to operate efficiently and in the best interests of its clients.  For example, CCDA may use or disclose your health information to The Council on Accreditation to insure that the Family Services Department maintains its status as an accredited provider of counseling and mental health services.

Uses and Disclosures to Business Associates

CCDA discloses your health information, without your authorization, to its business associates, which are third parties that assist CCDA in its operations.  For example, CCDA may share your health information with a financial auditor so that CCDA’s operations can be audited.  CCDA enters into agreements with its business associates to ensure that the privacy of your health information is protected from unauthorized disclosure.

Uses and Disclosures Requiring An Opportunity to Agree or Object

      Notification and Others Involved In Your Care.  In limited instances, your health      information may be used or disclosed to a family member, close personal friend, or others who CCDA has verified are involved in your care or payment for your care. Also, CCDA may use or disclose your health information to notify or assist in notifying a family member, close personal friend or others who CCDA has verified are involved in your care or payment for your care about your general condition, location (such as in the hospital) or death.  If you do not want this information to be shared, you may request that these disclosures be restricted as outlined later in this Notice.

 


Other Uses and Disclosures That May Be Made Without Your Authorization

The federal health privacy law provides for specific uses or disclosures of your health information that CCDA may make without your authorization, which are described below.

1.   Required by Law.  CCDA may use and disclose health information about you as required by federal, state or local law.  For example, CCDA may disclose your health information for the following purposes:

·        For judicial and administrative proceedings pursuant to court or administrative order, legal process and authority.

·        To report information related to victims of abuse, neglect, or domestic violence.

·        To assist law enforcement officials in their law enforcement duties.

 

2.   Health and Safety.  Your health information may be disclosed to avert a threat to the health or safety of you, any other person, or the public, pursuant to applicable law.  Your health information also may be disclosed for public health activities, such as preventing or controlling disease or disability, and meeting the reporting and tracking requirements of governmental agencies such as the Food and Drug Administration.

 

3.   Government Functions.  Your health information may be disclosed to the government for specialized government functions, such as intelligence, national security activities, and protection of public officials.  Your health information also may be disclosed to health oversight agencies that monitor the health care system for audits, investigation, licensure, and other oversight activities.

 

4.   Active Members of the Military and Veterans.  Your health information may be used or disclosed to comply with laws related to military service or veterans’ affairs.

 

5.   Workers Compensation.  Your health information may be used or disclosed in order to comply with laws related to Workers’ Compensation.

 

6.  Emergency Situations.  Your health information may be used or disclosed to a family member or close personal friend involved in your care in the event of an emergency, or to a disaster relief entity in the event of a disaster.

 

7.   Personal Representatives.  Your health information may be disclosed to people you have authorized or people who have the right to act on your behalf.  Examples of personal representatives are parents for minors, and those who have Power of Attorney for adults.

 

8.   Treatment and Health-Related Benefits Information.  CCDA and its business associates may contact you to provide information about appointment reminders, treatment alternatives or other health-related benefits and services that may be helpful to you.

 

9.   Research.  Under certain circumstances, CCDA may use or disclose your health information for research purposes, as long as the procedures required by law to protect the privacy of the research data are followed.

 

10. Organ and Tissue Donation.  If you are an organ donor, your health information may be used or disclosed to an organ donor, eye, or procurement organization to facilitate an organ or tissue donation or transplantation.

 

11. Deceased Individuals.  The health information of a deceased individual may be disclosed to coroners, medical examiners, and funeral directors so that those professionals can perform their duties.

 

Uses and Disclosures for Fundraising and Marketing Purposes. 

CCDA does not use your health information for fundraising or marketing purposes.

Any Other Uses and Disclosures Require Your Express Authorization

Uses and disclosures of your health information other than those described above will be made only with your express written authorization.  You may revoke your authorization in writing.  If you do so, CCDA will not use or disclose your health information authorized by the revoked authorization, except to the extent that CCDA already has relied on your authorization.

Once your health information has been disclosed pursuant to your authorization, the federal privacy protections may no longer apply to the disclosed health information, and that information may be re-disclosed by the recipient without your or CCDA’s knowledge or authorization.

YOUR HEALTH INFORMATION RIGHTS

You have the following rights regarding your health information that CCDA collects and maintains.  To exercise these rights, except for the Right to Complain or the Right to a Paper Copy of this Notice, you must make your request in-person at CCDA.  Upon your arrival at CCDA, you will be asked to complete a request form and you may be asked to present photo-identification as proof of your identity.  In addition, if you are making a request on behalf of an individual for whom you are the legal representative, you will have to present proof of your representative relationship with that individual at the time that you make the request.  If you have any questions about how to exercise these rights, please contact:

David Cavanaugh, LCSW, Privacy Officer      

3838 Cathedral Lane, Arlington, VA 22203     

703-841-2531                                                    

 

 


Right to Inspect and Copy Health Information

You have the right to inspect and obtain a copy of your health record maintained by the CCDA. This includes, among other things, health information about your care, treatment and billing records.

 

As explained above, to inspect and copy your health record maintained by CCDA, you must come to CCDA in-person to fill out the appropriate form, and you may be asked to present your photo-identification.  CCDA charges a fee of $.50 per page for the cost of copying your health record, and charges you the cost of mailing your health record to you.  In certain limited circumstances, CCDA may deny your request to inspect and copy your health record.  If CCDA does so, it will inform you in writing.  In certain instances, if you are denied access to your health record, you may request a review of the denial.

Right to Request Confidential Communications, or Communications by Alternative Means or at an Alternative Location

You have the right to request that CCDA communicate your health information to you in confidence by alternative means or in an alternative location.  For example, you can ask that CCDA only contact you at work or by mail, or that CCDA provide you with access to your health information at a specific location.

As explained above, to request confidential communications by alternative means or at an alternative location, you must come to CCDA in-person to fill out the appropriate form, and you may be asked to present your photo-identification.  In addition, you should be prepared to inform CCDA the alternative means by or location at which you would like to receive your health information, and, if appropriate, whether the disclosure of all or part of your health information by non-confidential communications could endanger you.  CCDA will accommodate reasonable requests and will notify you appropriately.

Right to Request That Your Health Information Be Amended

You have the right to request that CCDA amend your health information if you believe the information is incorrect or incomplete. 

As explained above, to request an amendment, you must come to CCDA in-person to fill out the appropriate form, and you may be asked to present your photo-identification.  In addition, you should be prepared to detail the reason(s) that support your request.  CCDA may deny your request if you have asked to amend information that:

·        Was not created by CCDA, unless you provide CCDA with information that the person or entity that created the information is no longer available to make the amendment;

·        Is not part of your heath information maintained by or for CCDA;

·        Is not part of the information which you would be permitted to inspect and copy; or

·        Is accurate and complete.

 

CCDA will notify you in writing as to whether it accepts or denies your request for an amendment to your health information.  If CCDA denies your request, it will explain the reason(s) for the denial, and describe how you can continue to pursue the denied amendment.

Right to an Accounting of Disclosures

You have the right to receive a written accounting of disclosures.  The accounting is a list of disclosures of your health information by CCDA to others, except that disclosures for treatment, payment or health care operations, disclosures made to or authorized by you, and certain other disclosures are not part of the accounting.  The accounting covers up to six years prior to the date of your request, except that the accounting will not include disclosures CCDA made before April 14, 2003.  And, you may request an accounting that covers a period that is less than six years.

As explained above, to request an accounting of disclosures, you must come to CCDA in-person to fill out the appropriate form, and you may be asked to present your photo-identification.  The first accounting that you request within a twelve month period will be free.  For additional accountings in a twelve month period, CCDA will charge you for the cost of providing the accounting, but CCDA will notify you of the cost involved before processing the accounting so that you can decide whether to withdraw your request before any costs are incurred. 

Right to Request Restrictions

You have the right to request restrictions on your health care information that CCDA uses or discloses about you to carry out treatment, payment or health care operations.  Also, you have the right to request restrictions on your health information that CCDA discloses to someone who is involved in your care or the payment for your care, such as a family member or friend.  CCDA is not required to agree to your request for such restrictions, and CCDA may terminate its agreement to the restrictions you requested.  As explained above, to request restrictions, you must come to CCDA in-person to fill out the appropriate form, and you may be asked to present your photo-identification.  In addition, you should be prepared to advise CCDA as to what information you seek to limit, and how and/or to whom you would like the limit(s) to apply.  CCDA will notify you in writing as to whether it agrees to your request for restrictions.  CCDA will also notify you in writing if it terminates an agreement to the restrictions that you requested.

Right to Complain

You have the right to complain to CCDA and/or to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.  To file a complaint with CCDA, submit your complaint in writing to (you do not need to come to CCDA in person to file a complaint):

David Cavanaugh, LCSW, Privacy Officer      

3838 Cathedral Lane, Arlington, VA 22203     

703-841-2531                                                    

 

 

You will not be retaliated or discriminated against and no services, payment, or privileges will be withheld from you because you file a complaint with CCDA or with the Department of Health and Human Services.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice.  To make such a request, submit a written request to (you do not need to come to CCDA in person to make this request):

David Cavanaugh, LCSW, Privacy Officer      

3838 Cathedral Lane, Arlington, VA 22203     

703-841-2531                                                    

 

 

You may also obtain a copy of this Notice at CCDA’s website, www.ccda.net .

CHANGES IN CCDA’S PRIVACY PRACTICES

CCDA reserves the right to change its privacy practices and make the new practices effective for all health information that it maintains, including your health information that it created or received prior to the effective date of the change and your health information it may receive in the future.  If CCDA materially changes any of its privacy practices, it will revise its Notice, and post the revised Notice at its locations.  In addition, copies of the revised Notice will be made available to you upon request, and any revised Notice will also be available at CCDA’s website, www.ccda.net .

 

EFFECTIVE DATE

This Notice is effective as of April 14, 2003, and will remain in effect unless and until CCDA publishes a revised Notice.