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. If you have any questions about this Notice please contact the Community Support Services Privacy Officer at:
Community Support Services, Inc.,
150 Cross Street
Akron, Ohio 44311
This Notice of Privacy Practices describes how the agency may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Community Support Services is required to abide by the terms of this Notice of Privacy Practices. Community Support Services may change the terms of this notice at any time. The new notice will be effective for all PHI that the agency maintains at that time. Any new version of the Notice of Privacy Practices will be publicly displayed. You may request a copy of the revised Notice of Privacy Practices by emailing email@example.com, calling the Privacy Officer and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information (PHI)
Uses and Disclosures of PHI Based Upon Your Written Consent
Upon admission you are asked to sign an Informed Consent for Treatment form. This consent form permits Community Support Services to use and disclose PHI for treatment, payment and health care operations.
Following are examples of the types of uses and disclosures of PHI that is permitted. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made once you have provided consent.
Treatment, Payment, and Health Care Operations (TPO): Community Support Services will use and disclose PHI for purposes of treatment, payment, and as otherwise necessary and permitted by law, for our health care operations. This may include disclosure to another health care provider who, at the request of your treatment team, becomes involved in your treatment, or for purposes of approval of reimbursement for your health care coverage.
Business Associates: At times, it may be necessary for Community Support Services to share PHI to certain outside persons or organizations that assist Community Support Services in the health care operations, such as auditing, shared services, accreditation, legal services, etc. These business associates are required to properly safeguard the privacy of your PHI.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that we have already taken an action based on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
Community Support Services may use and disclose PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then staff may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.
Appointment Reminders: Community Support Services may use PHI to remind you that you have an appointment for treatment or services. If you wish to opt out of the appointment reminder service, you must sign a declination form. Declination forms are made available upon request.
Others Involved in Your Healthcare: With your approval and using our professional judgment, PHI may be disclosed to designated family, friends, and others who are directly involved in your care or in payment of your care. Finally, we may use or disclose PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: Community Support Services may use or disclose PHI in an emergency treatment situation. If this happens, appropriate staff shall try to obtain your consent as soon as reasonably possible after the delivery of treatment.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
Community Support Services may use or disclose your PHI in the following situations without your consent or authorization. These situations include:
Required By Law: Community Support Services may use or disclose PHI to the extent the law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: Community Support Services may disclose PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. Community Support Services may also disclose PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: Community Support Services may disclose PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: Community Support Services may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: Community Support Services may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: Community Support Services may disclose PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: Community Support Services may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: Community Support Services may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of Community Support Services, and (6) medical emergency (not on our premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: Community Support Services may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for organ, eye or tissue donation purposes.
Research: Community Support Services may disclose PHI to researchers when an Institutional Review Board has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Criminal Activity: Consistent with applicable federal and state laws, Community Support Services may disclose PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Community Support Services may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, Community Support Services may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. Community Support Services may also disclose PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: PHI may be disclosed as authorized to comply with workers’ compensation laws and other similar legally established programs.
Inmates: Community Support Services may use or disclose PHI if you are an inmate of a correctional facility and your treatment staff created or received PHI in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
2. Your Rights
Following is a statement of your rights with respect to PHI and a brief description of how you may exercise these rights.
You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that the agency uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact the Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your PHI. This means you may ask Community Support Services not to use or disclose any part of PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your treatment staff is not required to agree to a restriction that you may request. If your treatment staff believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your treatment staff does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your treatment staff. You may request a restriction by contacting the Privacy Officer.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. Community Support Services will accommodate reasonable requests. Community Support Services may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Community Support Services will not request an explanation from you as to the basis for the request. Please make this request in writing to the Privacy Officer.
You may have the right to have your treatment staff amend your PHI. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, Community Support Services may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the Privacy Officer to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures Community Support Services has made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Community Support Services Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact the Privacy Officer at (330) 253-9388 or firstname.lastname@example.org for further information about the complaint process.