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ASF NOTICE OF PRIVACY PRACTICES
HIPAA (Health Insurance Portability and Accountability Act)

I. 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.

II. IT IS ASF’S LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law, ASF is required to insure that your PHI is kept private. The PHI constitutes information created or noted by ASF that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. ASF is required to provide you with this Notice of Privacy Practices. This Notice must explain when, why and how ASF would use and/or disclose your PHI. Use of PHI means when ASF shares, applies, utilizes, examines, or analyzes information within the agency; PHI is disclosed when ASF releases, transfers, gives, or otherwise reveals it to a third party outside the agency. With some exceptions, ASF may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. However, ASF is always legally required to follow the privacy practices described in this Notice.

Please note that ASF reserves the right to change the terms of this Notice and the agency’s privacy policies at any time. Any changes will apply to PHI already on file with ASF. Before ASF makes any important changes to the policies, ASF will immediately change this Notice and post a new copy of it in the office and on the website. You may also request a copy of this Notice from ASF or you can view a copy of it in the office or on the ASF website, which is located at www.ocasf.org.

III. HOW ASF WILL USE AND DISCLOSE YOUR PHI.
ASF will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of the agency’s uses and disclosures, with some examples. Although the new HIPAA language allows for disclosure of PHI related to treatment, payment, and healthcare operations, ASF will continue to abide by the stricter California State Law. Except for specific circumstances, federal and/or state law require special protections for medical information related to mental health, alcohol and drug abuse, HIV/AIDS, Sexually Transmitted Disease, and California Children’s Services. According to applicable law, we will not use or disclose these or other specially protected medical information without your written authorization.

A. Your Medical information may be used for:

1. Treatment. Information obtained by healthcare providers will be recorded in your medical record and may be used by other health care providers to determine your plan of care. For example, different providers may share medical information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays and to determine that you are receiving the proper treatment.

2. Payment. We may release medical information to your health plan or health insurance carrier to obtain payment for health services that you receive. For example, we may need to give your health plan information about your health in order to receive reimbursement for Home Health Care.

3. Health Care Operations. We may use your medical information for health care operations to make sure that the services and care provided to you are appropriate and of high quality. For example, we may combine medical information about many individuals to research health trends or to determine what service and programs we should offer. We may share your medical information with other providers who perform case management, coordination of care or other assessment activities.

B. Certain Uses And Disclosures Do Not Require Your Consent. ASF may use and/or disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: we may make a disclosure to the appropriate officials when a law requires us to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.

3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.

4. If disclosure is compelled by the client or the client’s representative pursuant to California Health and Safety Codes or to corresponding federal statutes or regulations, such as the Privacy Rule that requires this Notice.

5. To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.

6. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.

7. If disclosure is mandated by the California Child Abuse and Neglect Reporting Law. For example if we have a reasonable suspicion of child abuse or neglect.

8. If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting Law. For example if we have a reasonable suspicion of elder abuse or dependent adult abuse.

9. If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

10. For public health activities. Example: in the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.

11. For health oversight activities. Example: we may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.

12. For specific government functions. Examples: we may disclose PHI of military personnel and veterans under certain circumstances. Also, we may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.

13. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.

14. For Worker’s Compensation purposes. We may provide PHI in order to comply with Workers’ Compensation laws.

15. Appointment reminders and health related benefits or services. Examples: We may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.

16. If an arbitrator or arbitration panel compels disclosure. When arbitration is lawfully requested by either party, pursuant to subpoena duces tecum (e.g. a subpoena for mental health records), or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

17. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess our compliance with HIPAA regulations.

18. If disclosure is otherwise specifically required by law.

C. Certain Uses And Disclosures Require You To Have The Opportunity To Object. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other individual who you designate in writing is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.

D. Other Uses And Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIB, and IIIC above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to prohibit any future uses and disclosures of your PHI by ASF.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are your rights with respect to your PHI:

A. The right to see and get copies of your PHI. In general you have the right to see your PHI that is in our possession, or to get copies of it; however, you must request it in writing. If we do not have your PHI, but we know who does, we will advise you how you can get it. You will receive a response from ASF within 30 days of our receiving your written request. Under certain circumstances, we may feel that we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have our denial reviewed.
If you ask for copies of your PHI, ASF will charge you not more than $.25 per page. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on uses and disclosures of your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or permitted to make.

C. The Right To Choose How We Send Your PHI To You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). We are obliged to agree to your request provided that we can give you the PHI, in the format you requested, without undue inconvenience.

D. The Right To Get A List Of The Disclosures We Have Made. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one request in the same year, in which case ASF will charge you a reasonable sum based on a set fee for each additional request.

E. The Right To Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that ASF correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than ASF. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.

F. The Right To Get This Notice By Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.

V. HOW TO COMPLAIN ABOUT ASF’S PRIVACY PRACTICES
If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in section VI below. You may also send a written complaint to the Department of Health and Human Services, Office of Civil Rights, 50 United Nations Plaza, Room 322, San Francisco, CA 94102. If you file a complaint about our privacy practices, we will take no retaliatory action against you.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT ASF’S PRIVACY PRACTICES
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact the ASF Privacy Officer:

Scott Blaisdell, Deputy Director - Clinical Services
17982 Sky Park Circle, Suite J
Irvine, CA 92614-6408
(949) 809-5700
HIPAA@ocasf.org

NOTICE OF PRIVACY PRACTICES:

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices. Our Notice of Privacy provides information about how we may use and disclose your medical information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting the designated ASF Privacy Officer or by accessing the revised copy on the ASF website at WWW.OCASF.ORG.

If you have any questions about our Notice of Privacy Practices please contact the ASF Privacy Officer:

Scott Blaisdell, Deputy Director - Clinical Services
17982 Sky Park Circle, Suite J
Irvine, CA 92614-6408
(949) 809-5700
HIPAA@ocasf.org

I acknowledge receipt of the Notice of Privacy Practices:

Signature: _________________________________ Date: ____________

Print Name: __________________________________________________

INABILITY TO OBTAIN ACKNOWLEDGEMENT – to be completed by ASF staff only if signature is not obtained.

Please describe the good faith efforts made to obtain the client’s acknowledgement, and the reasons why the acknowledgement was not obtained:

______________________________________________________________

______________________________________________________________

Signature: _________________________________ Date: ____________
(ASF Staff)

Print Name: __________________________________________________
(ASF Staff)

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