APT FOUNDATION 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.
The APT Foundation is federally mandated to
maintain the privacy of your health information and wants you to know about our
practices for protecting your health information. APT is required to abide by
the terms of this notice. The information we maintain may come from any of the
providers from whom you have received services. The information we record and
maintain is known as Protected Health Information, or PHI. We will not use or
disclose your PHI without your permission, except as described in this notice.
We reserve the right to change our
practices and to make the new provisions effective for all PHI we maintain.
Should our information practices change, we will amend the notice and make the
notice available upon request on or after the new effective date of the notice.
This notice is effective as of April 14, 2003.
Definitions:
|
Individual refers to the person who is the subject of the protected health information. |
Treatment is the provision, coordination, or management of health care and related services by one or more health care providers. |
|
|
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Protected Health Information means individually identifiable health information that is maintained and transmitted on any form. |
Payment consists of the activities undertaken by either a health plan or health care provider to obtain or provide reimbursement for the provision of health care. |
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Authorization is the permission granted by the client or the client’s guardian to use or disclose PHI for purposes other than health care operations. |
Health Care Operations consists of the administrative, financial, and legal activities that support the essential health care functions of treatment and payroll. |
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Uses and Disclosures: In
general, it is our policy to obtain written authorization for release of
information prior to a disclosure. You may revoke an authorization at any time.
|
We
may use your PHI without authorization for: Treatment,
e.g., share information with Apt staff involved in your care Payment,
e.g., to bill and collect payment for your health care services Healthcare
operations, e.g., to evaluate the quality of services provided Reminding
you of appointments |
Other
permitted disclosures of your PHI without authorization might include the
following: Disclosures
required by law, e.g., when a law requires that we report suspected abuse,
neglect or domestic violence Medical
Research, e.g., medication trials Public
Health, e.g., mandated reporting of disease, injury or vital statistics To avert a serious threat to health or
safety As
a response to a court order If
deceased, to coroners, medical examiners or funeral directors Workers’
compensation claims if under investigation Correctional
Institutions if incarcerated |
127a 3/03
What are your rights? You
have the right to:
·
Request
restrictions on certain uses and disclosures of PHI. APT reserves the right to
deny the restrictions, to which you may make a further appeal.
·
Receive
confidential communication of PHI by an alternative method, e.g., mailing to an
address other than your home address
·
Inspect
and copy your health record by written request
·
Request
an amendment of your PHI. APT must
consider the request, but may deny the amendment.
·
Receive
an accounting of APT disclosures of your PHI
·
Receive
a paper copy of this notice upon request
How you can report a
problem?
If you feel your privacy rights have been
violated, you may file a complaint with the APT Foundation Privacy Officer (Bob
Freeman, 203-781-4600), or the Secretary of the United States Department of
Health and Human Services.
Would you like more
information? If you have
questions and would like more information, you may contact the APT Foundation
Privacy Officer.
APT FOUNDATION, INC.
NEW HAVEN, CT DDU
NUMBER: ______________
The confidentiality of alcohol, drug abuse, and HIV/AIDS status documented in patient records, which are maintained by APT Foundation programs are protected by Federal law and regulations. Generally, our programs may not reveal to a person outside of the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser or as HIV/AIDS positive unless:
1. The patient consents 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 these Federal Laws and Regulations is a
crime. Suspected violations may be
reported to appropriate authorities in accordance with Federal Regulations.
Federal Law and Regulations do not protect the
reporting of any information about a crime committed by a patient either on the
program premises or against any program staff.
Federal and State Laws and Regulations do not
protect any information about suspected child abuse or neglect from being
reported under State Law to appropriate State or Local Authorities.
____________________________________________________________________________________________
I understand that my
alcohol and/or drug treatment records are protected under the federal
regulations governing Confidentiality and Drug Abuse Patient Records, 42 CFR
Part 2, under Connecticut General Statutes Sec. 17a-688 and the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR pts 160
and 164, and cannot be disclosed without my written consent, unless otherwise
provided for in these regulations and statutes.
I understand I have the right to file a complaint
with the Secretary of the Department of Health & Human Services. Any such
complaint must be filed within 180 days of the time I knew or should have known
that the APT Foundation was not in compliance. The complaint should be mailed
to the U.S. Department of Health and Human Services, Office of Civil Rights,
I acknowledge that I have received a copy of the
Notice of Privacy Practices. I understand that if I have further questions or
complaints I may contact: Bob Freeman at
781-4600, APT Foundation, Inc. 1 Long Wharf Drive, Suite 321,
Finally, I understand that I am entitled to
receive updates upon request if the APT Foundation’s Notice of Privacy
Practices is amended or changed in a material way.
____________________________________________________ ______________________________
PATIENT SIGNATURE D.O.B. DATE
____________________________________________________
WITNESS SIGNATURE
If consumer does not sign, or refuses to sign,
please indicate reason(s): _________________________________________
_______________________________________________________________________________________________________________________________________
079, Rev. 04/07