Privacy Policy

Notice of Privacy Practices Regarding Protected Health Information

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This notice of privacy practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA), which went into effect on April 14, 2003. It describes how we may  use or disclose your protected health information, with whom that information
may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information except when the release is required or authorized by law, contract or regulation.

Acknowledgement of receipt of this notice
You will be asked to provide a signed receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your protected health care services will in no way be conditioned upon your signature. If you decline to sign the Notice of Privacy Practice Receipt, we will continue to serve you as a customer of the Aging and Disability Resource Center (ADRC) and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

Our Legal Duty
“Protected health information” is individually identifiable protected health information. This information is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains demographic information about you, the provider of service, dates of service, medications, diagnosis, diagnostic tests, symptoms and any other relevant demographic information needed for current treatment.

Protected health information also includes mental health/AODA psychotherapy notes, assessments, progress notes or discharge summaries. These documents require additional informed consent in order to be released or disclosed and are not held within the “designated record set.”

The ADRC is required by law to do the
following:

• Ensure your protected health information is kept private
• Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information
• Follow the terms of the notice currently in effect
• Communicate changes in the notice

The ADRC reserves the right to change our privacy practices and the terms of this notice at any time provided such applicable law permits the changes. When we make a significant change in our privacy practices we will change this notice and make the new notice available upon request. You have the right to a copy of the ADRC Notice of Privacy Practice at any time.
Copies are available on request and on our web site at www.adrcofbrowncounty.org.

Required Uses and Disclosures of Your Protected Health Information
The ADRC will use and disclose protected health information about you for treatment, payment and health care operations. This may include diagnosis, treatment, personal address and other identifying information.

By law, we are able to use or disclose your
protected health information, held within
your designated record set, without your
authorization for the following purposes:

Treatment
The ADRC will use your protected health information to provide you treatment, determine functional eligibility and/or to provide services. For example, we may consult with internal, contract or other business associate professionals to provide them with information they need to make decisions about your care or services.

Payment
In some cases the ADRC may use your protected health information in order to receive reimbursement from third-party payers for services provided, i.e.: in determining your eligibility, via a functional screen.

Health Care Operations
The ADRC may use and disclose your protected health information for regular service operations or to detect and prevent health care fraud or abuse. Regular service operations include quality assessment, improvement activities, certification, licensing or credentialing activities. There are some services provided in our organization through contracts with business associates or service providers. When these services are contracted, we may disclose your personal protected health information to our business associates so they can perform the job we’ve asked them to do. To protect your protected health information, however, we require the business associate to be subject to the federal privacy rules so they can appropriately safeguard your information. We will not sell your protected health care information to anyone.

Disaster Relief
The ADRC may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and can disclose to family or individuals involved in your health care.

Communications to You
The ADRC may use your information to communicate appointment reminders or to request additional information. These communications may be by phone, mail or other means at your request. We also may contact you with information about programs or services that may be of interest to you or that can improve your health. A survey may be mailed to you after your visit.

Required or Permitted By Law
In certain circumstances we may report some of your protected health information to legal entities such as law enforcement officials or government agencies. We may disclose your information in response to a court order or for certain types of administrative proceedings where the law permits or requires us to disclose information.

Public Health Reasons
We may disclose your protected health information to a public health authority that is permitted by law to collect or receive the information. This information may be used to prevent or control disease, injury or disability.

The agency is committed to protecting and reporting potential abuse of children, vulnerable

Health Oversight Activities
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.

These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights authorities.

Death Records
We may disclose your protected health information to coroners, medical examiners, and funeral directors, as required or permitted by law, so they can carry out their duties related to your death.

Organ Donation
We may disclose your protected health information to entities involved in obtaining, banking or transplanting organs, eyes or tissue for donation or transplantation purposes.

Research
We may disclose your protected health information to researchers only when approved or authorized by law.

Health and Safety Threat
We may disclose your protected health information to the necessary authorities if we believe in good faith that such use or disclosure is necessary to prevent or minimize a serious or imminent threat to you or the public’s health or safety.

Incarceration, Law Enforcement Custody
and National Security
We may disclose your protected health information if you are in the custody of law enforcement officials or an inmate in a correctional institution or a threat to national security.

Workman’s Compensation
We may disclose your protected health information to the appropriate persons in compliance with workers’ compensation laws. For example, your employer may be provided with information about your work related injury.

Communication with Family and Friends
If you are not physically available or cognitively able to grant informal permission, we are permitted to use our professional judgment to determine whether disclosing is in your best interest and determine you would otherwise allow such a disclosure. We may disclose your protected health information (but not in written record form) to your family, friend or other person identified by you and involved in your care.

On Your Authorization
You may give us written or verbal authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it verbally or in writing at any time. Unless you give us written or verbal permission, the ADRC cannot use or disclose your protected health information for any reason except those allowable by law, contract or regulation. All other disclosures of your personal health care information will require an authorization by you.

Your Rights Regarding Protected Health Care Information:
Inspect or Obtain a Copy of Your Protected Health Care Information

You may inspect and obtain a copy of your protected health information that is contained in your “designated record set” for as long as we maintain the protected health information. A fee may be charged for the cost of copying, mailing and other related supplies. Should you request additional supplemental information from outside of your designated record set (mental health, AODA assessments or progress notes), a written request or additional releases may apply.

Right to Request Restrictions
You have the right to request restrictions on how your protected health information is used or to whom your protected health care information is disclosed for any of the following situations: treatment, payment, health care operations, notification or communication to family or friends, and disclosure to disaster relief agencies. Your request must be in writing to the ADRC Privacy Officer when you wish the restriction to be instituted. In your request, you must inform us: 1) what information you want restricted; 2) whether you want to restrict our use, disclosure or both; 3) to whom you want the restriction to apply, for example disclosures to your spouse; 4) and an expiration date. We are not required to agree in all circumstances to your request for the restriction. While we will consider your request, because of the number, complexity and nature of services we provide, we may not be able to grant your request.

Right to Request Amendments
You do not have the right to change your protected health information. You have the right to request that we clarify your protected health information by adding information to your records. Your request must be in writing, must explain why the information should be amended and be sent to our privacy officer. The ADRC has the right to deny your request. The denial will be in writing. You may respond with a statement in writing as to why you disagree with the decision and it will be added to the record. If we agree to amend the records as requested, then we may also make reasonable efforts to inform others, including specific parties named by you, of the changes.

Accounting of Disclosures
The ADRC must keep a record of who your protected health information is disclosed to.  You have the right to see the disclosure record. You may request this information from the ADRC Privacy Officer.

Confidential Communications
You may request that we communicate with you using alternative means or at an alternative location. For example, you may request that we only call you at your work phone number or that we never leave a voice mail at your home. We will accommodate reasonable requests when possible.

Complaints
If you believe these privacy rights have been violated, you may present in person, call, or file a written complaint with the ADRC. Your complaint will not affect the care and service we provide to you in the present or in the future.

Contact Information:
Privacy Officer
Aging and Disability Resource Center
of Brown County
300 South Adams Street
Green Bay WI 54301
Voice Phone: (920) 448-4300
FAX: (920) 448-4306

TDD: WI Relay 711
Region V – Chicago (Illinois, Indiana,
Michigan, Minnesota, Ohio, Wisconsin)

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone: (312) 886-2359
FAX: (312) 886-1807
TDD: (312) 353-5693