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City of Chesapeake
Community Services Board

224 Great Bridge Blvd
Chesapeake, VA 23320

Phone (757) 547-9334

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.

Why We Have This Privacy Notice

We are required by law to maintain the privacy of protected health information, and to provide you with notice of our legal duties and our privacy practices with respect to this protected health information. Also, we must abide by the terms of this Notice. If we make any changes in the Notice, we must notify you before the change can take effect. We reserve the right to change the terms of this Notice and to make any new Notice provisions effective for all protected health information that we maintain. You will be asked to acknowledge that you have received this Notice, and you have a right to have a hard copy of this Notice.

In order to effectively provide services to individuals the Chesapeake Community Services Board (“CCSB”) must utilize and in some cases disclose information about individuals receiving services. We must do that in order to provide services. This Notice explains how we may use and disclose information about you. It also describes your rights to see, amend, and control your “protected health information”(PHI), which is defined as “information related to your past, present or future physical or mental health or condition and related health care services, including demographic information that may identify you..”  This Notice is about the use and disclosure of your “PHI”. Sometimes the word” information” or the word “record(s)” or the phrase “medical record(s)” will be used. When they appear in this Notice, they mean the same thing as “PHI”. The word “individual”, when used in this notice, refers to you and other clients of the CSB. If you have any questions about this Notice, or about any of the CCSB’s privacy policies, procedures or practices, please call us at (757) 548-7011, and ask to speak with our Privacy Officer.

Permitted Uses and Disclosures of Protected Health Information without the Written Authorization of the Individual: Treatment, Payment and Health Care Operations. Medical privacy laws try to make sure that the protection of your privacy does not interfere with your ability to get treatment. Therefore, the law allows us to use and disclose your protected health information, without asking for your prior authorization, for the following purposes:

FFOR TREATMENT PURPOSES: Your protected health information may be shared among staff and consultants of the CCSB as part of the treatment process at the CCSB.

EXAMPLE:  a therapist may speak to a psychiatrist about the need for medication. During those consultations, health information about you will be shared. Your protected health information may be shared with another treatment provider who is treating you. EXAMPLE:  if you had to go to the hospital and your treating physician there asked CCSB staff about medications you are taking, that information could be shared with your treating physician to help that physician give you better care.

FFOR PAYMENT PURPOSES: In order to get paid for providing treatment to you, the CCSB must send some treatment information about you to the company (such as your health insurance company) that is responsible for paying for that treatment. Such companies have a right to review treatment information about you to make sure that the treatment meets their standards for payment. Therefore, we may use information about you to arrange for payment (for example, preparing bills and managing accounts), and we may disclose information to others (such as insurers, collection agencies and consumer reporting agencies) to get payment. The CCSB will provide only the “minimum necessary information” required by such companies for us to get paid.

 EXAMPLE: The Department of Mental Health, Mental Retardation and Substance Abuse Services and the Department of Medical Assistance Services (which administers Medicaid) pay for treatment provided to some clients of the CCSB. Both departments have the authority to review the treatment records of clients to make sure that treatment meets their standards.

FFOR HEALTH CARE OPERATIONS: There are a number of ways in which your protected health information must be used and disclosed by CCSB staff in order to carry out a variety of program activities that are called “health care operations”. These operations are needed to help us to, for example, review and improve the quality of our services and find more effective and efficient ways to serve you.

EXAMPLES: Our professional staff reviews treatment records to make sure that they are accurate, complete, and organized. This is part of our quality assurance program. In addition, we may review treatment records if necessary in taking disciplinary or other corrective action toward a staff person who has not performed properly. Those records may also be reviewed in grievance hearings about such disciplinary or corrective action.

We conduct medical, financial, and legal audits and reviews of our practices and records to make sure that we are doing our job right. Different staff may be involved in reviewing your record as part of this process. We also cooperate with outside organizations that review treatment records to evaluate, certify or license our staff or our program. In addition to CCSB staff, the CCSB may receive help in its health care operations from other departments of the City of Chesapeake, such as the City Auditor, the City Attorney, and the Finance Department. It may also contract with professionals in other organizations to help. These persons and departments are required to keep confidential any protected health information they receive in doing this work. We sometimes provide training programs for students, trainees and others to help them practice or improve their skills

Other Permitted Uses and Disclosures of Protected Health Information Without Written Authorization of the Individual

FREQUIRED BY LAW:  We may use and disclose information about you whenever we are required by law to do so. There are many federal and state laws that require us to use and disclose information about individuals receiving services from us. We will comply with those requirements, and will limit the information we provide to what is required by law.

EXAMPLES: Virginia law requires us to report to certain persons or agencies if an individual who is receiving services threatens to harm another individual. We are required by Virginia law to report to the local department of social services information that we have that leads us to suspect that a child has been abused or neglected.

We are publicly funded by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS). Virginia Code Section 37.1-197 (B) (16) requires the CCSB to release your PHI to the DMHMRSAS, but also requires the DMHMRSAS to implement procedures to protect the confidentiality of this information.   Under the authority of this statute, the DMHMRSAS currently requires us to release your PHI to the DMHMRSAS as part of its Community Consumer Submission (CCS) system. Data from that system is used to support the DMHMRSAS’s requests for public funding. DMHMRSAS states that it uses an encryption system to prevent anyone from being able to identify you as a client of the CCSB.

FPUBLIC HEALTH AUTHORITIES:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. These disclosures normally are made for such purposes as preventing, controlling or investigating diseases and injuries to persons, and monitoring drugs or devices regulated by the Food and Drug Administration (FDA)

EXAMPLES: We may also be required to report information that you have been exposed to a communicable disease. For the purpose of preventing or controlling disease, injury or disability we are required to report certain information to the Health Department. This includes vital events such as death.

FHEALTH OVERSIGHT ACTIVITIES:  Virginia statutes have set up a number of agencies and offices that monitor treatment providers like the CCSB to make sure that they are providing proper care and are complying with the law. These and other agencies may also monitor insurance companies and others who may pay for our services. These agencies and offices have the authority to review treatment records of individuals as part of their oversight of providers.

EXAMPLES: We are licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services. Therefore, staff of the Department’s licensure office and its human rights office, as well as the Inspector General for the Department, have the authority to review your record as a part of their reviews of our CSB. The Virginia Office of Protection and Advocacy (VOPA) was created by the Virginia General Assembly as an independent body that monitors the treatment of persons with disabilities in different settings, including treatment settings. They have the right to review the records of individuals receiving treatment services as part of their job to ensure that these individuals are being treated right. Government agencies responsible for investigating insurance fraud also have the authority to review CCSB records.

FLEGAL PROCEEDINGS: We may disclose protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, to the extent that the order requires us. We may also respond to subpoenas, discovery requests or other lawful process, but in those cases the persons seeking the information must meet certain legal requirements to protect the records. Our normal practice is to contact you whenever we receive a subpoena or order to disclose your records.  

FLAW ENFORCEMENT: We may disclose information about you to a law enforcement official for certain specific law enforcement purposes.

EXAMPLE: We may disclose information about you to a police officer if the officer needs the information to help find or identify a missing person or to catch a criminal suspect.

FSERIOUS THREATS TO HEALTH OR SAFETY: We may disclose information about you if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, but only to persons who may be able to prevent or lessen the threat.

FCORONERS, FUNERAL DIRECTORS, AND ORGAN DONATION:  We may disclose information about you to a coroner, medical examiner, or funeral director, or to organizations that help with organ, eye and tissue transplants.

FRESEARCH: We may disclose information about you to researchers when their research has been approved by an institutional review board that has approved the research and has required the researchers to protect the privacy of your information.

FMILITARY ACTIVITY AND NATIONAL SECURITY: Under certain conditions, we may disclose information to military authorities about individuals receiving services from us who are in the military. We may also disclose information to authorized federal officials for national security and intelligence activities.

FINMATES: If you are an inmate in a correctional or detention facility, we may disclose information about you to that facility for certain treatment and safety purposes.

FWORKERS’ COMPENSATION: We may disclose information about you in order to comply with workers’ compensation laws.

FSECRETARY OF HEALTH AND HUMAN SERVICES: We must disclose information as required by the Secretary of U.S. Department of Health and Human Services for purposes of making sure that we are complying with the Privacy Rule developed under the Health Insurance Portability and accountability Act (HIPAA).

ENHANCING YOUR HEALTHCARE: Some of our programs use and disclose your information in order to provide the following support to enhance your overall health care:

Uses and Disclosures of Protected Health Information in Which You Have an Opportunity to Agree or Object

FFACILITY DIRECTORIES: The CCSB has some day programs and residential programs. We may maintain a directory of individuals who are in those programs, and will let people know, when they call or come by and specifically ask for you by name, that you are there. You can restrict or stop this.

FINVOLVEMENT BY OTHERS IN INDIVIDUAL'S CARE: We may disclose information to a family member, other relative, close personal friend or other person you identify,  IF that information is directly related to such person’s involvement in your treatment or payment for your treatment.

 EXAMPLE: You ask that your sister be present at a meeting with your treating clinician. We may also let them know where you are or if something has happened to you.   Usually, this will be done only if you are present and do not object. In some situations (for example, picking up a prescription for you), this disclosure may be made without your being present. You may ask us at any time not to disclose information about you to persons involved in your care.

We will follow your request, except in limited circumstances (such as emergencies).  Our usual practice is to get your written authorization to disclose information to others.

FDISASTER RELIEF: We may use or disclose information about you to an agency providing disaster relief in cases where their help is needed. We will try to get your permission before doing this.

Other Uses and Disclosures of Your Information: Written Authorization Required

Other uses and disclosures of information not covered by this Notice or the laws that apply to the CSB will be made only with your written authorization. If you authorize us to use or disclose information about you, you may revoke that authorization at any time. That authorization must be in writing and must be given to your treating clinician, or your case manager, or the Privacy officer, before it becomes effective. If you revoke your authorization, we will stop using or disclosing the information that was covered in your authorization (unless we have independent legal authority to use or disclose it). When you revoke an authorization to disclose information, we cannot take back any disclosures we have already made with your authorization.

(NOTE: Complaints to the Secretary of HHS should be made no later than 180 days after the privacy violation occurred or you became aware (or reasonably should have been aware) that the privacy violation had occurred. This time limit may be extended for good cause.)

A complaint can be made in person, over the phone or by mail.

Alcohol and Drug Abuse Information

The privacy of information held by the CCSB which identifies, or could identify, a person as an alcohol or drug abuser, is controlled by a specific federal privacy law. The privacy standards of 42 CFR Part 2 (authorized by 42 U.S.C. 290dd-3and 42 U.S.C. 290ee-3) are often more restrictive than the standards set out in this Notice, and we must follow the more restrictive standards. Generally, the CCSB may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser unless:   (1) you authorize it in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the CCSB or against any person who works for the CCSB or about any threat to commit such a crime. They also do not protect against any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Minors

Under Virginia law, minors are deemed to be adults for purposes of giving consent to outpatient treatment for substance abuse or for mental health services. Under federal law (42 CFR Part 2), a minor who becomes a patient for substance abuse treatment has the same authority as any adult patient in regard to the privacy of his or her treatment records. The minor’s parents, guardian, or legal custodian can have access to treatment records only with the minor’s permission. However, in the case of a minor who is receiving outpatient mental health services, the minor’s parents, guardian, or other legal custodian also have a right of access to the minor’s records. There are certain narrow exceptions in which a parent, guardian, or other legal custodian can be denied access to a minor’s records.

Personal representative

When an individual is incapacitated or otherwise unable to give informed consent to treatment or authorization for the disclosure of records, that person’s “personal representative” may exercise the authority of the individual in regard to the privacy of the individual’s records. A “personal representative” is a person authorized under Virginia law to give substitute authorization for the individual, such as a guardian, attorney-in-fact, or, under certain circumstances and procedures, a family member or other person designated as a “legally authorized representative” under Virginia’s Human Rights regulations. However, the individual must be included in decisions about disclosing information, to the extent that the individual is able, and, unless the personal representative is a guardian with specific authority to act, any objection by the individual to a disclosure of records, even if the personal representative approves, must be reviewed before we can disclose the information. Finally, a personal representative’s access to an individual’s information can be denied if a licensed health care professional determines in the individual’s record that such access by the personal representative is reasonably likely to cause substantial harm to the individual or to another person.

Changes to Privacy Practices

The CCSB reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law. You will receive notice of changes in one or more of the following ways: mail; discussion with an agency representative; electronically; a notice prominently posted in a public area, such as the waiting room.

EFFECTIVE DATE: April 14, 2003; revised 4/7/05

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