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Tennyson Center Client Privacy

NOTICE OF PRIVACY PRACTICES


THIS NOTICE DESCRIBES HOW MEDICALAND MENTAL HEALTH INFORMATION ABOUT A CHILD MAY BE USED AND DISCLOSED AND HOW A PARENT OR GUARDIAN CAN GET ACCESS TO THIS INFORMATION.


PLEASE REVIEW IT CAREFULLY.

We respect the privacy of our clients’ personal health information and are committed to
maintaining the confidentiality of this information. This Notice of Privacy Practices (Notice)
applies to all client health information and records that our agency has received or created. It
extends to information received or created by our employees, staff, volunteers and physicians.
This Notice informs you about the possible uses and disclosures of client personal health
information. It also describes client rights and our obligations regarding personal health
information.


We are required by law to:
 Maintain the privacy of your protected health information;
 Provide to clients this detailed Notice of our legal duties and privacy practices relating to
personal health information; and
 Abide by the terms of the Notice that are currently in effect.

I. WAYS WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE
OPERATIONS

A parent, guardian or legal custodian will be asked to sign an acknowledgment indicating you
have received our Notice of Privacy Practices (Notice) detailing how we will use and disclose
a child’s personal health information for purposes of treatment, payment and health care
operations. We have described these uses and disclosures below and provide examples of the
types of uses and disclosures we may make in each of these categories.

For Treatment. We will use and disclose client personal health information in providing the
child with treatment and services. We may disclose personal health information to agency and
non-agency personnel who may be involved in the child’s care, such as therapists, physicians,
and nurses. For example, the agency nurse may report any change in the child’s physical
condition to a physician. We also may disclose personal health information to individuals who
will be involved in the child’s care after s/he leaves our facility or programs.

For Payment. We may use and disclose personal health information so that we can bill and
receive payment for the treatment and services the child has received at the agency. For billing
and payment purposes, we may disclose personal health information to the child’s parent or
guardian, a case worker, insurance or managed care company, Medicare, Medicaid or another
third party payor, including state and county departments of human services, as well as school
districts. For example, we may contact Medicare or a health plan to confirm coverage or to
request prior approval for a proposed treatment or service.

For Health Care Operations. We may use and disclose personal health information for facility
operations. These uses and disclosures are necessary to manage the facility and to monitor our
quality of care. For example, we may use protected client information to evaluate our agency’s
services, including the performance of our staff, to provide notices or reports, or to provide
other needed services.


II. WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION
ABOUT A CHILD FOR OTHER SPECIFIC PURPOSES SUCH AS THE
FOLLOWING:

As Required By Law. We will disclose a child’s personal health information when required by
law to do so.


Public Health Activities. We may disclose personal health information for public health
activities. These activities may include, for example:

 reporting to a public health or other government authority for preventing or controlling
disease, injury or disability, or reporting child abuse or neglect;
 reporting to the Federal Food and Drug Administration (FDA) concerning adverse
events or problems with products for tracking products in certain circumstances, to
enable product recalls or to comply with other FDA requirements;
 to notify a person who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading a disease or condition; or
 for certain purposes involving workplace illnesses or injuries.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that a child has
been a victim of abuse, neglect or domestic violence, we may use and disclose personal health
information to notify a government authority if required or authorized by law.
Health Oversight Activities. We may disclose personal health information to a health
oversight agency for oversight activities authorized by law. These may include, for example,
audits, investigations, inspections and licensure actions or other legal proceedings. These
activities are necessary for government oversight of the health care system, government
payment or regulatory programs, and for compliance with other federal, state or local laws.

Judicial and Administrative Proceedings. We may disclose personal health information in
response to a court or administrative order. We also may be required to disclose information in
response to a subpoena, discovery request, or other lawful process. In those cases, an effort must be made to contact the child’s parent or guardian about the request or to obtain a court order or agreement protecting the information.

Law Enforcement. We may disclose personal health information for certain law enforcement
purposes, including:
 as required by law to comply with reporting requirements;
 to comply with a court order, warrant, subpoena, summons, investigative demand or
similar legal process;
 to identify or locate a suspect, fugitive, material witness, or missing person;
 when information is requested about the victim of a crime if the individual agrees or
under other limited circumstances;
 to report information about a suspicious death;
 to provide information about criminal conduct occurring at the facility;
 to report information in emergency circumstances about a crime; or
 where necessary to identify or apprehend an individual in relation to a violent crime or
an escape from lawful custody.

To Avert a Serious Threat to Health or Safety. We may use and disclose personal health
information when necessary to prevent a serious threat to a child’s health or safety or the health
or safety of the public or another person. However, any disclosure would be made only to
someone able to help prevent the threat.

Worker’s Compensation. We may use or disclose personal health information to comply with
laws relating to workers’ compensation or similar programs.

Fundraising Activities. We may use certain personal information to contact members of the
child’s immediate family in an effort to raise money for the agency and its operations, and our
parent organization, the National Benevolent Association. We may disclose personal
information to a foundation related to the facility so that the foundation may contact you in
raising money for the facility. In doing so, we would only release contact information, such as
your name, address and phone number and the dates you received treatment or services at the
facility.

Appointment Reminders/Notices/Reports. We may use or disclose personal health information
to remind the child or his/her family about appointments, to provide required notices of
meetings, or to provide reports.

Treatment Alternatives. We may use or disclose personal health information to provide
information about treatment alternatives.

Health-Related Benefits and Services. We may use or disclose personal health information to
inform about health-related benefits and services that may be of interest to you.


III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF PERSONAL
HEALTH INFORMATION


We will use and disclose personal health information (other than as described in this
Notice or required by law) only with a written Authorization from the child’s parent or
guardian. An Authorization to use or disclose personal health information may be revoked in
writing at any time. If the Authorization is revoked, we will no longer use or disclose personal
health information for the purposes covered by the Authorization, except where we have already
relied on the Authorization or as required by law.


IV. RIGHTS REGARDING PERSONAL HEALTH INFORMATON

Clients have the following rights regarding personal health information at the facility:

Right to Request Restrictions. A child, acting through his/her parent or guardian, has the right
(a) to request restrictions on our use or disclosure of personal health information for treatment,
payment or health care operations; and (b) to restrict the personal health information we
disclose to a family member, friend or other person who is involved in the child’s care or the
payment for such care.

For clients that participate in the Medicare and/or Medicaid program: We are required
to agree to a requested restriction unless the child is being transferred to another health
care institution, the release of the records is required by law, or the release of information
is needed to provide emergency treatment.

For all others: We are not required to agree to a requested restriction. If we do agree to
accept the requested restriction, we will comply with the request except as needed to
provide the child with emergency treatment.

Right of Access to Personal Health Information. A child’s parent or guardian has the right to
inspect and obtain a copy of medical or billing records or other written information that may be
used to make decisions about the child’s care, subject to some limited exceptions. We may
charge a reasonable fee for our costs in copying and mailing requested information.
We may deny a request to inspect or receive copies in certain limited circumstances. If you are
denied access to personal health information, in some cases you will have a right to request
review of the denial. This review would be performed by a licensed health care professional
designated by the facility who did not participate in the decision to deny.

Right to Request Amendment. A child’s parent or guardian has the right to request the facility
to amend any personal health information maintained by the facility for as long as the
information is kept by or for the facility. Any such request must be made in writing and must
state the reason for the requested amendment.

We may deny your request for amendment if the information:
 was not created by the facility, unless the originator of the information is no longer
available to act on our request;is not part of the personal health information maintained by or for the facility;
 is not part of the information to which you have a right of access; or
 is already accurate and complete, as determined by the facility.

If we deny a request for amendment, we will give you a written denial including the reasons
for the denial and the right to submit a written statement disagreeing with the denial.

Right to an Accounting of Disclosures. You have the right to request an “accounting” of our
disclosures of your personal health information. This is a listing of certain disclosures of your
personal health information made by the facility or by others on our behalf, but does not
include disclosures for treatment, payment and health care operations or certain other
exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time
period beginning after April 13, 2003 that is within six years from the date of your request. An
accounting will include, if requested: the disclosure date; the name of the person or entity that
received the information and address, if known; a brief description of the information
disclosed; a brief statement of the purpose of the disclosure or a copy of the authorization or
request; or certain summary information concerning multiple similar disclosures. The first
accounting provided within a 12-month period will be free; for further requests, we may charge
you our costs.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this
Notice, even if you have agreed to receive this Notice electronically. You may request a copy
of this Notice at any time.

Right to Request Confidential Communications. A child’s parent or guardian has the right to
request that we communicate concerning the child’s personal health matters in a certain
manner or at a certain location. For example, you can request that we contact you only at a
certain phone number. We will accommodate your reasonable requests.


V. COMPLAINTS

If you believe that a child’s privacy rights have been violated, you may file a complaint in
writing with the facility or with the Office of Civil Rights in the U.S. Department of Health
and Human Services. To file a complaint with the unit, contact the Director of Human
Resources, who is the agency’s Privacy Officer. We will not retaliate against you if you file a
complaint.


VI. CHANGES TO THIS NOTICE

We will promptly revise and distribute this Notice whenever there is a material change to the
uses and disclosures, to individual client’s rights, our legal duties, or other privacy practices
stated in this Notice. We reserve the right to change this Notice and to make the revised or
new Notice provisions effective for all personal health information already received and
maintained by the facility as well as for all personal health information we receive in the
future. We will post a copy of the current Notice in the facility. In addition, we will provide a
copy of the revised Notice to all patients.


VII. FOR FURTHER INFORMATON

If you have any questions about this Notice or would like further information concerning your
privacy rights, please contact the agency’s Director of Human Resources, who is our unit’s
designated Privacy Officer.