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 Program Coordinator for the site that supports your services and supports. WHO WILL FOLLOW THIS NOTICE This notice describes our practices and that of: Any health care professional authorized to enter information into your health record. All divisions and programs of the Agency. Any volunteer we allow to help you while you are receiving services from the Agency. All employees, staff and other personnel. All Agency entities, sites and locations follow the terms of this notice. Staff members at these entities, sites and locations may share health information with each other for treatment, payment or operations purposes as described in this notice. OUR PLEDGE REGARDING HEALTH INFORMATION We understand that health information about you and your health is personal. We are committed to protecting your privacy and health information about you. We create a record of the care and services you receive at the Agency. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Agency, whether made by Agency personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your health information created in the doctor's office or clinic. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to: Make sure that health information that identifies you is kept private; Give you this notice of our legal duties and privacy practices with respect to health information about you; and Follow the terms of the notice that is currently in effect. Comply with any state law that is more stringent or provides you greater rights than this Notice. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. For Treatment. We may use health information about you to provide you with treatment or services. We may disclose information about you to doctors, nurses, clinicians, case managers, interns, or other Agency personnel who are involved in providing services to you. For example, a clinician might be treating you for a mental health problem and need to talk with one of our psychiatrists or another clinician who has specialized training in a particular area of care. We may also disclose information about you to people outside the Agency who are involved in your health care. For Payment. We may use and disclose health information about you so that the treatment and services you receive at the Agency may be approved by, billed to, and payment collected from a third party such as an insurance company or developmental services funding committee. For example, we may need to give your health plan information about counseling you received at the Agency so your health plan will pay us or reimburse you for a counseling service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the service/treatment. For Health Care Operations. We may use and disclose health information about you for Agency operations. These uses and disclosures are necessary to run the Agency and make sure that all individuals receiving services from us receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in serving you. We may also combine health information about many consumers to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, clinicians, case managers, interns and other Agency personnel for review and learning purposes. We may also combine the health information we have with health information from other mental health agencies to compare how we are doing and see where we can make improvements in the services we offer. We will remove informaiton that identifies you from this set of health informaton so others may use it to study health care and health care delivery without learning who the specific consumers are. Appointment Reminders. We may use and disclose information to contact you as a reminder that you have an appointment. Alternative Treatment and Benefits and Services. We may use and disclose information about you in order to obtain and recommend to you other treatment options and available services as well as other health-related benefits or services. Fundraising Activities. Should the need arise where information about you or where your participation is desired for fundraising activities, the Agency would obtain your authorization. No information would be released for this purpose without your authorization. For example, if the Agency was creating a fundraising brochure and picture of or comments from persons served were desired, the Agency would inquire whether or not you would be willing to participate. Participation would be voluntary and if you agreed, you would be asked to give us written authorization for this specific purpose. Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all consumers who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with consumer's need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for consumers with specific health needs, so long as the health information they review does not leave the Agency. We will always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the Agency. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. In Vermont, this would include: victims of child abuse; the abuse, neglect or exploitation of vulnerable adults; or where a child under the age of 16 is a victim of a crime; and firearm-related injuries. Under certain circumstances, the Department of Developmental and Mental Health Services is mandated access to health information in order to carry out its responsibilities. To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. SPECIAL SITUATIONS Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. Workers' Compensation. We may release health information about you as authorized for workers' compensation or similar programs as authorized by Vermont law. These programs provide benefits for work-related injuries or illnesses. Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following: To prevent or control disease, injury or disability; To report deaths; To report child abuse or neglect; To report abuse, neglect or exploitation of vulnerable adults; any suspicion of abuse, neglect, or exploitation of the elderly (age 60 or older), or a disabled adult with a diagnosed physical or mental impairment, must be reported; To report reactions to medications or problems with products; To notify individuals of recalls of products they may be using; To notify an individual who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Health Oversight Activities. We may disclose health information to a health oversight agency, such as the Department of Developmental and Mental Health Services, for activities authorized by law. These oversight activities include, but are not limited to, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Legal Proceedings and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Public Health Officials and Funeral Home Directors. We may release information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information to funeral directors thereby permitting them to carry out their duties. Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution. OTHER USES OF HEALTH INFORMATION Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the services that we provided to you. YOUR RIGHTS REGARDING INFORMATION ABOUT YOU Any assistance (physical, communicative, etc.) you need in order to exercise your rights will be provided to you by the Agency. Right to Review and Copy. You have the right to review and copy health information that may be used to make decisions about your care. This may include both health and billing records. To review and copy health information that may be used to make decisions about you, you must submit your request in writing to the Program Coordinator. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny or limit access to your request to inspect and copy in certain very limited circumstances. If you are denied or limited access to health information, you may request that the decision be reviewed. Another health care professional chosen by the Agency will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.   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 the information is kept by or for the Agency. To request an amendment, your request must be made in writing and submitted to the author or health information department. 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 that request. In addition, we may deny your request if you ask us to amend information that:   was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the designated record set kept by or for the Agency; is not part of the information which you would be permitted to inspect and copy; or, was determined accurate or complete by the Agency.   Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you which were required by law and/or were not authorized by you. To request this list or accounting of disclosures, you must submit your request in writing to the Program Coordinator. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you for the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.   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. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member. For example, you could ask that we not use or disclose information about a counseling session you received. To request restrictions, you must make your request in writing to the Program Coordinator. 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 limits to apply, for example, disclosures to your spouse.   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 mail. To request confidential communications, you must make your request in writing to the Program Coordinator. 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.   Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of the current notice at any time. To obtain a paper copy of this notice, contact the Program Coordinator.   Security of Health Information. Due to the nature of community based human service practices, Agency representatives may possess individually identifiable information beyond the physical security of the Agency. In these cases, Agency representatives will ensure the security and confidentiality of the information in a manner that meets Agency policy, State and Federal Law.   CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in all Agency facilities. The notice will contain on each page, in the top right-hand corner, the effective date. In addition, should we make a material change to this notice, we will, prior to the change taking effect, publish an announcement of the change at every Agency facility, on its website and in the local paper. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the Agency or with the Secretary of the Department of Health and Human Services. To file a complaint with the Agency, contact one of the following: BRADFORD: Program Coordinator - Lorraine Gaboriault 802-222-9235 MORETOWN: Program Coordinator - Dennis Gray 802-496-7830 RANDOLPH: Program Coordinator - Joan Carman 802-728-4476 BRATTLEBORO: Program Coordinator - Brandon Pedigo 802-258-6580 All complaints must be submitted in writing. Complaint forms are available at each location including the reception area at the Agency's main office. You will not be penalized for filing a complaint. The Secretary of the Department of Health and Human Services can be contacted through their regional office at: Office of Civil Rights U.S. Department of Health and Human Services Government Center John F. Kennedy Federal Building - Room 1875 Boston, MA 02203 Voice Phone: (617) 565-1340 Fax: (617) 565-3809 TDD: (617) 565-1343