THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice, please contact the Dempsey Centers Privacy Officer:
Name: Lisa Balsam
Address: 29 Lowell Street, Lewiston, ME
Phone: (207) 795-8250
1. Summary of Rights and Obligations Concerning Health Information
Dempsey Centers organization is committed to preserving the privacy and confidentiality of your health information. This Notice serves to advise you of the ways in which we may legally use and disclose your health information that is created, received or retained by this organization.
We retain information regarding the fact that you are a client. We may receive health information from other treating providers that you make available to us. Each time you receive any health care related services from us, we document the service rendered. This record may contain a diagnosis, treatment, and a plan or recommendations for future care or treatment. As a legal and ethical matter, we will protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information where you have expressly authorized us to do so, or, even without express authorization, to:
• plan your care and treatment;
• provide treatment;
• communicate with other providers such as referring physicians;
• make quality assessments and work to improve the care we render and the outcomes we achieve, known as health care operations;
• make you aware of other services, available resources, programs or treatment that may be of interest to you; and
• comply with state and federal laws that require us to disclose your health information.
You have certain rights to access your health information. You have the right to:
• ensure the accuracy of your health record;
• request confidential communications between you and your Dempsey Centers provider and request limits on the use and disclosure of your health information; and
• request an accounting of certain uses and disclosures of health information we have made about you.
We are required to:
• maintain the privacy of your health information;
• provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy organizations with respect to information we collect and maintain about you;
• abide by the terms of our most current Notice of Privacy Practices;
• notify you if we are unable to agree to a requested restriction; and
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve the right to change our organizations and to make the new provisions effective for all your health information that we maintain.
Should our information organizations change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.
In the following pages, we explain our privacy organizations and your rights to your health information in more detail.
2. We May Use or Disclose Your Health Information In The Following Ways
A. Treatment. We may use and disclose your health information to provide
you with health care treatment or services. We will record your current healthcare information in a record so, in the future, we can see your health history to help in diagnosing and treatment, or to determine how well you are responding to treatment. We may provide your health information to other health providers, such as referring or specialist physicians, to assist in your treatment. Should you ever be hospitalized, we may provide the hospital or its staff with the health information it requires, if any, to provide you with effective treatment.
B. Payment. If this organization charged or billed in any way for the services, we would legally be permitted to use and disclose your health information so that we could bill and collect payment for the services. This organization provides its services free of charge as part of its charitable mission and no disclosures will be made with respect to billing or collections, unless you expressly authorize disclosure to an insurer to confirm if and when you become ineligible to receive Dempsey Centers services.
C. Health Care Operations.
We may use and disclose your health information to assist in the operation of our organization with respect to delivery of the health care services you receive. For example, members of our staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the services we provide. We may use and disclose your health information to conduct cost-management and business planning activities for our organization.
D. Business Associates. This organization sometimes contracts with third-party business associates for services. Examples include answering services, transcriptionists, consultants, and legal counsel. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information, and such business associates are only entitled to the minimum information necessary, if any, to perform the work they are contracted to do.
E. Appointment Reminders. We may use and disclose information in your health record to contact you as a reminder that you have an appointment with a provider in this office. We may call you the day before your appointment and leave a message for you. However, you may request that we provide such reminders only in a certain way or only at a certain place. We will endeavor to accommodate all reasonable requests.
F. Treatment Options. We may use and disclose your health information to inform you of alternative treatments, through mailings such as newsletters or notices or other means of communication.
G. Release to Family/Friends. Our health professionals, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person’s involvement in your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law or if we determine that such disclosure would not be in the best interest of the minor client.
H. Solicitations and Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits, products or services that may be of interest to you. In any fund-raising types of communications, or similar solicitations, you will have the opportunity to opt out of receiving such information. The opt-out procedures will be made available to you at such time, if ever, that we undertake any such solicitations.
I. Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief organizations seek your health information to coordinate your care, or notify family and friends of your location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
J. Marketing. We are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may provide you with promotional gifts of nominal value. Under no circumstances will we sell our client lists or your health information to a third party without your written authorization.
K. Public Health Activities. We may disclose health information about you for public health activities. These activities generally include the following:
• licensing and certification carried out by public health authorities;
• prevention or control of disease, injury, or disability;
• reports of births and deaths;
• reports of child abuse or neglect;
• notifications to people who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition;
• organ or tissue donation; and
• notifications to appropriate government authorities if we believe a client has been the victim of abuse, neglect, or domestic violence. We will make this disclosure when required by law, or if you agree to the disclosure, or when authorized by law and in our professional judgment disclosure is required to prevent serious harm.
L. Funeral Directors. We may disclose health information to funeral directors upon request and as may be necessary so that they may carry out their duties.
M. Food and Drug Administration (FDA). We may disclose information, upon request, and as may be necessary, to the FDA and other federal and state regulatory agencies, relating to adverse events with respect to food, supplements, products and product defects, or post-marketing monitoring information to enable product recalls, repairs, or replacement.
N. Psychotherapy Notes. We may not disclose psychotherapy notes, if any, taken by a mental health professional during a private counseling session without your written authorization, except under extremely limited circumstances such as for reporting of abuse, neglect, or domestic violence, or a threat of serious and imminent harm made by you. Dempsey Centers does not typically create or maintain psychotherapy notes, which are notes maintained separately from a health or medical record.
O. Research. We may disclose your health information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.
P. Workers Compensation. We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Q. Law Enforcement. We may release your health information:
• in response to a court order, subpoena, warrant, summons, or similar process if authorized under state or federal law;
• to identify or locate a suspect, fugitive, material witness, or similar person;
• about the victim of a crime if, under certain limited circumstances, we are
unable to obtain the person’s agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at our office location;
• to coroners or medical examiners;
• in emergency circumstances to report a crime, the location of the crime or
victims, or the identity, description, or location of the person who committed
• to authorized federal officials for intelligence, counterintelligence, and other
national security authorized by law; and
• to authorized federal officials so they may conduct special investigations or
provide protection to the President, other authorized persons, or foreign
heads of state.
R. De-identified Information. We may use your health information to create “de-identified” information or we may disclose your information to a business associate so that the business associate can create de-identified information on our behalf. When we “de-identify” health information, we remove information that identifies you as the source of the information. Health information is considered “de-identified” only if there is no reasonable basis to believe that the health information could be used to identify you.
S. Personal Representative. If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information. If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative.
T. HLTV-III Test. If we perform, or obtain or maintain information in our records regarding, an HLTV-III test on you (to determine if you have been exposed to HIV), we will not disclose the results of the test to anyone but you without your written consent unless otherwise required by law. We also will not disclose the fact that you have taken the test to anyone without your written consent unless otherwise required by law.
U. Limited Data Set. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health, and health care operations. We may not disseminate the limited data set unless we enter into a data use agreement with the recipient in which the recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security of the data, and not identify the information or use it to contact any individual.
3. Authorization for Other Uses of Health Information
Uses of health information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. If you provide us with authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.
4. Your Health Information Rights
You have the following rights regarding health information we gather about you:
A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.
B. Right to Inspect and Copy. You have the right to inspect and copy health information in your record that may be used to make decisions about your care. To inspect and copy health information, you must submit a written request to our Privacy Officer. We will supply you with a form for such a request. If you request a copy of your health information, we may charge a reasonable fee, per state law, for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your health information for a claim for benefits under the Social Security Act (such as claims for Social Security, or Supplemental Security Income or any other state or federal needs-based benefit program).
We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. A licensed healthcare professional who was not directly involved in the denial of your request will conduct the review. We will comply with the outcome of the review.
If your health information is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable cost-based fee limited to the labor costs associated with transmitting the electronic health record.
C. Right to Amend. If you feel that 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 we retain the information. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
1) correct and complete;
2) not created by us or not part of our records, unless there is a reasonable basis to believe that the originator of the PHI is no longer available to act on the requested amendment; or
3) not allowed to be disclosed. If you do submit a proposed amendment, we are required to indicate whether we agree with the proposed amendment, or disagree, and take such actions as required under the federal regulations with respect to notifications about the same.
D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including:
• disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations, however, if the disclosures were made through an electronic health record, you have the right to request an accounting for such disclosures that were made during the previous 3 years;
• disclosures made pursuant to your authorization;
• disclosures made to create a limited data set;
• disclosures made directly to you.
To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than six years. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.
E. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. If you paid out-of-pocket for a specific item or service, you have the right to request that health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we are required to honor that request. You also have the right to request a limit on the health information we communicate about you to someone who is involved in your care or the payment for your care. Except as noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us:
• what information you want to limit;
• whether you want to limit our use, disclosure, or both; and
• to whom you want the limitations to apply.
F. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by e-mail. To request confidential communications, you must make your request in writing to our
Privacy Officer. We will not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how or where you wish to be contacted.
G. Right to Receive Notice of a Breach. In the event of a breach of the security or confidentiality of your health information, we shall notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), as soon as possible, but in any event, no later than 60 days following the discovery of the breach. “Unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice shall include information such as:
• a brief description of the breach, including the date of the breach and the date of its discovery, if known;
• a description of the type of Unsecured Protected Health Information involved in the breach;
• steps you should take to protect yourself from potential harm resulting from the breach;
• a brief description of actions we are taking to investigate the breach, mitigate losses, and protect against further breaches;
• contact information, including a toll-free telephone number, e-mail address, Web site or postal address to permit you to ask questions or obtain additional information.
If you believe your privacy rights have been violated, you may file a complaint with us or with a government agency or you may pursue legal action in a state or federal court. To file a complaint with us, contact our Privacy Officer at the address listed above. Although the HIPAA laws and regulations do not apply to Dempsey Centers, you may wish to explore a report to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201, the organization that oversees HIPAA compliance. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for submitting any complaint or expressing any concern regarding the confidentiality of your health information.