Notice of Privacy Practices
Effective April 14,2003
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:
Director of Health Information/Privacy Officer
(585) 467-2230 Ext. 35
Delphi Drug & Alcohol Council, Inc is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. as Notice of Privacy Practices describes how we may use and disclose your personal health information to carry out treatment, payment or health care activities and for other purposes that are permitted or required by law. It also describes your rights to access and control your personal health information. “Personal health information” 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.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all personal health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
7.1. How Delphi Drug & Alcohol Council, Inc may Use or Disclose Your Health Information
Delphi Drug & Alcohol Council, Inc collects health information fiom you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Delphi Drug & Alcohol Council, Inc, but the information in the medical record belongs to you. Delphi Drug & Alcohol Council, Inc protects the privacy of your health information. The law permits Delphi Drug & Alcohol Council, Inc to use or disclose your health information for the following purposes:
Uses and Disclosures of Personal Health Information
Uses and Disclosures of Personal Health Information Based Upon Your Written Consent
Your personal health information may be used and disclosed by clinical staff, support staff and others that are involved in your care and treatment for the purpose of providing health care services to you. Your personal health information may also be used and disclosed to pay your health care bills and to support the operation of Delphi Drug & Alcohol Council, Inc.
Following are examples of the types of uses and disclosures of your personal health information that the agency is permitted to make. These are only seine examples that describe the types of uses and disclosures that may be made by our office once you have provided consent.
Treatment: We will use and disclose your personal health information to provide, coordinate, or manage your treatment and any related services. This includes the coordination or management of your treatment with anyone else you give permission to access to your records.
For example, we would disclose your personal health information, as necessary, to your health insurance provider that pays for service or to a physician from whom you may have been referred.
Payment: Your personal health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; Making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you and undertaking utilization review activities.
For example, treatment information may be disclosed to the health plan to obtain approval for payment of services.
Healthcare Operations: We may use or disclose your personal health information in order to support, the business activities of Delphi Drug & Alcohol Council, Inc These activities inclilde, but are not limited to, quality assessment activities, training of staff, licensing, and conducting or arranging for other business activities.
For example, we may use a sign-in sheet at the reception desk where you will be asked to sign your name and indicate your clinician. We may also call you by name in the waiting room when your clinician is ready to see you.
We will share your personal health information with third party “business associates” that perform various activities (e.g. auditing or legal services) for Delphi Drug & Alcohol Council, Inc. Whenever an arrangement between our office and a business associate involves the use or disclosure of your personal health information, we will have a written contract that contains terms that will protect the privacy of your personal health information.
Uses and Disclosures of Personal Health Information based upon Your Written Authorization.
Information that would identify you as a person seeking help for a substance abuse problem is protected under a separate set of federal regulations known as “Confidentiality of Alcohol and Drug Abuse Patient Records”, 42 C.F.R. Part 2. Under certain circumstances these regulations will provide your health information with additional privacy protections beyond those that have already been described.
Delphi Drug &Alcohol Council, Inc will follow the provisions of 42 CFR Part 2 governing disclosure ofpersonal health information. Except for the circumstances described below, we will not disclose personal health information to a thirdparty without written of the individual or a court order. Ifa request for disclosure ofyour patient record is received, you will be contacted and asked whether you wish to authorize disclosure. If you refirse to authorize disclosuue, or it is notpossiblefor us to contact you in person, we will not disclose your information without a court order.
If you do authorize Delph Drug & Alcohol Council, Lnc to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke authorization, it will not affect disclosure or use of information that has already occurred.
Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object.
We may use or disclose your personal health information in the following situations without your consent or authorization. These situations include:
- Pursuant to court order and subpoena
- Medical personnel in an emergency
- Suspected incidents of child abuse or neglect
- To agencies that provide regulatory authority
- Audit and evaluation activities
- To report crime (or threat of crime) on premises or against program personnel. Information is limited to circumstances, name and address, and last known whereabouts.
2. Your Rights
Following is a statement of your rights with respect to your personal health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your personal health information. This means you may inspect and obtain a copy of personal health information about you that is contained in a designated record set for as long as we maintain the personal health information. A “designated record set” contains medical and billing record and any other records that your clinician and 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 personal health information that is subject to law that prohibits access to personal health information.
Depending on the circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your personal health information. This means you may ask us not to use or disclose any part of your personal health information for the purposes of treatment, payment or healthcare operations. Your request must state the specific restriction requested and to whom you want the restriction to apply.
We do not have to agree to a requested restriction, but will consider your request. If we agree to the requested restriction, we may not use or disclose your personal health information 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 clinician. You may request a restriction by submitting a request in writing to your treatment provider.
You have the right to request to receive confidential communication from us by alternative means or at an alternative location. We will accommodate reasonable requests. We 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. We will not request an explanation from you as to the basis for the request. Please make this request in writing.
You may have the right to amend your personal health information. This means you may request an amendment of personal health information about you in a chart as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
You have the rieht to receive an accounting of certain disclosures we have made, if any, of your personal health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. You have the right to receive specific information regarding these disclosures that occurred after Apdl 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 compliant with us by notifying our privacy officer of your complaint. We will not retaliate against you for filing a compliant.
You may contact our Privacy Officer, Carl Hatch-Feir, at (585) 467-2230 Ext. 35 or send an e-mail to email@example.com for further information about the complaint process.
If you are not satisfied with the manner in which this office handles a compliant, you may submit a formal compliant to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S. W.
Room 509F HHH Building
Washington, DC 20201
You may also address your compliant to one of the regional Offices for Civil Rights. A list of these offices can be found online at: http://www.hhs.gov/ocr/dregrnail.html.
Through our diverse programs, Delphi successfully assists individuals, families and the community by working to find solutions to these serious problems. Drug and alcohol abuse and chemical dependency devastate individual, families and communities without regard to age, gender, race or socio-economic group.
NOTICE OF NON-DISCRIMINATION FOR A MEDICAL PRACTICE
WITH 15 OR MORE EMPLOYEES
DELPHI COMPLIES WITH APPLICABLE FEDERAL CIVIL RIGHTS LAWS AND DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGINAL, AGE, DISABILITY OR SEX. DELPHI DOES NOT EXCLUDE PEOPLE OF TREAT THEM DIFFERENTLY BECAUSE OF RACE, COLOR, NATIONAL ORIGINAL, AGE, DISABILITY, OR SEX.
- PROVIDES FREE AIDS AND SERVICES TO PEOPLE WITH DISABILITIES TO COMMUNICATE EFFECTIVELY WITH US, SUCH AS:
- QUALIFIED SIGN LANGUAGE INTERPRETERS
- WRITTEN INFORMATION IN OTHER FORMATS (LARGE PRINT, AUDIO ACCESSIBLE ELECTRONIC FORMATS, OTHER FORMATS)
- PROVIDES FREE LANGUAGE SERVICES TO PEOPLE WHOSE PRIMARY LANAGUAGE IS NOT ENGLISH, SUCH AS:
- QUALIFIED INTERPRETERS
- INFORMATION WRITTEN IN OTHER LANGUAGES
IF YOU NEED THESE SERVICES, CONTACT 585-467-2230 X435. IF YOU BELIEVE DELPHI HAS FAILED TO PROVIDE THESE SERVICES OR DISCRIMINATED IN ANOTHER WAY ON BASIS OF RACE, COLOR , NATIONAL ORIGIN, AGE, DISABILITY, OR SEX, YOU CAN FILE A GRIEVANCE WITH : CARL HATCH-FEIR, PRESIDENT/CEO, 585-467-2230 X435, EMAIL CHATCH-FEIR@DELPHIDRUG.ORG; FAX 585-625-3558 OR ANN M. GRAHAM, DIRECTOR OF OPERATIONS AND CARE SERVICES, 585-467-2230 X301, EMAIL AGRAHAM@DELPHIDRUG.ORG, FAX 585-625-3558, OR BY U.S. MAIL TO: DELPHI DRUG AND ALCOHOL COUNCIL, INC., 1839 EAST RIDGE ROAD, ROCHESTER, NY 14622.
YOU CAN FIELD A GRIEVANCE IN PERSON OR BY MAIL, FAX OR EMAIL. IF YOU NEED HEP FILING A GRIEVANCE, A STAFF PERSON IS AVAILABLE TO HELP YOU.
YOU CAN ALSO FILE A CIVIL RIGHTS COMPLAINT WITH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE FOR CIVIL RIGHTS, ELECTRONICALLY THROUGH THE OFFICE OF CIVIL RIGHTS COMPLAINT PORTAL, AVAILABLE AT HTTPS:/OCRPORTAL.HHS.GOV/OCR/PORTAL/LOBBY/JSF. OR BY MAIL OR PHONE:
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
200 INDEPENDENCE AVENUE, SW
ROOM 509F, HHH BUILDING
WASHINGTON, D.C. 20201
1-800-368-1019, 1-800-537-7697 (TDD)
COMPLAINT FORM ARE AVAILABLE AT HTTP://WWW.HHS.GOV/OCR/OFFICE/FILE/INDEX.HTML
LANGUAGE ASSISTANCE SERVICES
Updated October 14, 2016
ATTENTION: If you speak any of the following languages, language assistance services, free of charge, are available to you. Call 1-585-467-2230.
[SPANISH] ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
[CHINESE] 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-xxx-xxx-xxxx（TTY：1-xxx-xxx-xxxx）
[RUSSIAN] ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).
[FRENCH CREOLE] ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
[KOREAN] 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)번으로 전화해 주십시오.
[ITALIAN] ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন ১-xxx-xxx-xxxx (TTY: ১-xxx-xxx-xxxx)
[POLISH] UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-xxx-xxx-xxxx (رقم هاتف الصم والبكم: 1-xxx-xxx-xxxx).
[FRENCH] ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-xxx-xxx-xxxx (ATS : 1-xxx-xxx-xxxx).
خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
[TAGALOG] PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
[GREEK] ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).
[ALBANIAN] KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).