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.

I. WHO WE ARE

This Notice describes the privacy practices of the Florence Crittenton Services of Arizona, Inc., (Florence Crittenton), as they apply to all agency clinicians, therapists, counselors, case managers, interns, managers, supervisors, program and support staff, other personnel, contractors and volunteers. It applies to those services furnished to you on-site at Florence Crittenton’s Phoenix, Arizona campus as well as to community-based services provided to you at your home, school or other designated location.

II. OUR COMMITMENT TO YOUR PRIVACY

We understand that medical information about you and your health is personal. We appreciate the importance of keeping this information secure and private. We are committed to protecting all health information we maintain in our records about you. Keeping your personal health information safe is one of our most important duties.We limit access to this information to those who need it, typically the staff assigned to provide you services and the supervisors who monitor their work. We maintain appropriate safeguards to protect it. For example, we restrict access to our file rooms and computer system and have appointed a Security Officer to make sure that no one violates our security measures. Our Privacy Officer makes sure that staff are properly trained to obey the privacy policies and procedures we’ve developed to protect your personal information.

III. WHAT TYPES OF PERSONAL INFORMATION DO WE COLLECT?

To provide you with the highest quality of services, we need information about you to assess your needs and develop treatment plans. Some examples include your name, address, phone number, social security number, date of birth, education or employment information. Other examples may refer more specifically to your medical history, edications you’ve been prescribed and health care services you are receiving. This personal information is often referred to as Protected Health Information (PHI). PHI refers to any oral, written, electronic, visual, pictorial, physical, or other form of information that relates to your past, present, or future physical or mental health status,condition, treatment, service, products purchased, or provision of care, and which, whether named or unnamed, clearly relates specifically to you, revealing your identity.

IV. OUR LEGAL OBLIGATION TO YOU

This notice has been developed to tell you about the ways in which we may use and disclose your PHI. It also describes certain rights you have and obligations we have regarding the use and disclosure of your PHI.

The law to requires us to:
-Take reasonable steps to protect health information that identifies you from unauthorized disclosure;
-Give you this notice of our legal duties and privacy practices with respect to PHI about you; and
-Follow the terms of this notice or the most up-to-date version of this notice in effect at some future time when your PHI is used or disclosed.

This notice as well as any future revisions will be posted in each of our residential cottages, the cafeteria of the Crittenton Youth Academy, and the lobby of our counseling center. It is also available on-line at the Florence Crittenton Web Site, www.florencecrittentonofaz.org. You may also request that copies of future updates be sent to you by mail.

V. GUIDELINES FOR USING AND DISCLOSURING YOUR PHI

We may use and share your personal information for “treatment,” “payment” and “health care operations.” Below are examples of each. We may limit the amount of information we share about you as required by law. For example, the law may further protect HIV/AIDS, substance abuse, and genetic information. Our privacy policies will always reflect the most protective laws that apply.

Treatment:
We may use and disclose your personal information to Florence Crittenton personnel who are involved in diagnosing your condition or providing treatment or other services to you. We may also share this information with other clinicians or caregivers involved in your treatment such as physicians, hospitals, and case managers.

Payment:
We may use and disclose your personal information to obtain payment for any diagnostic, care, treatment or other supporting services that we provide to you. For example, we may release personal information about you to the Arizona Health Care Cost Containment System (AHCCCS), the State’s Medicaid program, Value Options, Central Arizona’s regional behavioral health authority, the Southwest Network, a contract provider of behavioral health services under Value Options, or from any other organization or entity that pays the cost of some or all of the
services you receive from Florence Crittenton.

Health Care Operations:
We may use or disclose, as needed, your PHI in order to support the business activities of Florence Crittenton. These activities include, but are not limited to, quality assessment, employee review, risk management activities, staff member training, licensing and accreditation. For example, Florence Crittenton regularly reviews the quality and content of the clinical charts for each Florence Crittenton program area. This requires that actual clinical records be reviewed on a random basis to ensure that clinical documentation meet the regulatory requirements under which we operate. In addition, we may call you by name in the waiting room when your clinician is ready to see you.

We will share your PHI with third party “Business Associates” that perform various activities for Florence Crittenton. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI. We may also use your demographic information in aggregation with other consumer demographic information to produce reports about Florence Crittenton operations to regulatory or funding bodies. We may remove information that identifies
you from this set of PHI so others may use it to study health care and health care delivery without learning who the specific covered persons are.

Appointment Reminders:
We may use and disclose PHI to contact you as a reminder that you have an appointment for treatment with your assigned clinician.

Treatment Alternatives:
We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services:
We may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you.

Marketing:
We may use or disclose PHI about you when we have face-to-face conversations with you about products or services that may be beneficial to you.

Client Census Reports:
We will use and disclose the location at which residential clients are receiving care. This client census is only available to Florence Crittenton staff members and to persons who have a need to know this information based upon the business that he/she is conducting at or with Florence Crittenton.

Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify your PHI that directly relates to that person’s involvement in your health care (ARS 36-509A.8). We may also give information to someone who helps pay for your care. If you are unable to agree or object to such person’s involvement, we will disclose only that information as necessary to your best interest, based upon our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death.
Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Communication Barriers:
We may use and disclose your PHI if your clinician attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the clinician, using professional judgment, determines that you intend to consent to use or disclose under the circumstances.

As Required By Law:
We will disclose PHI about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety:
We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Workers’ Compensation:
We may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks:
We may disclose PHI about you for public health activities. These activities generally include the following:
-To prevent or control disease, injury or disability;
-To report births and deaths;
-To report child abuse or neglect;
-To report reactions to medications or problems with products;
-To notify people of recalls of products they may be using;
-To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
-To notify the appropriate government authority if we believe a covered person has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:
We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and disciplinary actions. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes:
If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requesting.

Law Enforcement:
We may release PHI if asked to do so by law enforcement officials:
-As required by law;
-In response to a court order, subpoena, warrant, summons, administrative request or similar process;
-To identify or locate a suspect, fugitive, material witness, or missing person;
-About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
-About a death we believe may be the result of criminal conduct;
-If necessary to return you to services in response to a court order for treatment or evaluation; -About criminal conduct at the Florence Crittenton Call Center or Administration offices; -In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors:
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release PHI to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities:
We may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others:
We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates:
If you an inmate of a correctional institution or under custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

VI. OTHER USES OF YOUR PHI

Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose PHI about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care
that we provided to you. If you revoke your permission that was obtained as a condition of obtaining insurance coverage, other laws may still allow the insurance company to contest a claim under the policy.

Confidentiality of Substance Abuse Records:

For individuals who have received treatment, diagnosis or referral for treatment from our drug or alcohol abuse programs; federal law and regulations protect the confidentiality of drug or alcohol abuse records. In general, we may not tell a person outside the programs that you attend any of these programs, or disclose any information identifying you as an alcohol drug abuser, unless
-You authorize it in writing, or
-The disclosure is permitted by court order, or
-The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation purposes, or
-You threaten to commit a crime either at the program site or against any person who works for Florence Crittenton, or
-There is reason to suspect child abuse or neglect may be occurring.

Confidentiality of HIV or AIDS-related Information:
Disclosure of HIV or AIDS-related information is prohibited under Arizona state law. You must provide written authorization before Florence Crittenton will disclose this information.

VII. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you:

Right to Inspect and Copy:

You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include information compiled in anticipation of a legal proceeding or psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Client Records, Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013. If you request a copy of the information, we charge a fee for the copying costs or other supplies associated with your request and will provide you with access and/or copies within 30 days.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed behavioral health professional chosen by Florence Crittenton will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Request Restriction:

You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a psychiatric medication you may be taking.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to Client Records, Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your personal physician.

Right to Request Confidential Communications:

You have the right to request that we communicate with you about behavioral health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Client Records, Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and must contain a statement that disclosure of all or part of your PHI that you are requesting to be communicated to you in a certain way or at a certain location could endanger you.

Right to Amend:

If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Florence Crittenton.

To request an amendment, your request must be made in writing and submitted to Client Records, Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

-Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
-Is not part of the PHI kept by or for Florence Crittenton;
-Is not part of the information which you would be permitted to inspect and copy; or
-Is accurate and complete.

Right to an Accounting of Disclosures:

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of PHI about you. To request this list or accounting of disclosures, you must submit your request in writing to Client Records, Florence Crittenton Services of Arizona, Inc., 715 West Mariposa Street, Phoenix, AZ 85013. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of producing and providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy:

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. In addition, you must sign an acknowledgement that you have received this notice and that Florence Crittenton staff has reviewed it with you. To obtain a paper copy of this notice, please contact anyone at Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013.

VIII. CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice on the Florence Crittenton Website as well as in all buildings on the Florence Crittenton campus. The notice will contain, on the lower left-hand corner of each page, its effective date.

IX. CONTACT INFORMATION

If you have any questions about this Notice, please contact our Privacy Officer at (602) 288-4521 or at (602) 274-7318 x121. The Privacy Officer may also be contacted in writing at:

Privacy Officer, Florence Crittenton Services of Arizona, 715 West Mariposa Street, Phoenix, AZ 85013.

X. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Florence Crittenton or with the Secretary of the Department of Health and Human Services. To file a complaint with Florence Crittenton, contact our Privacy Officer, (602) 288-4521 or at (602) 274-7318 x121 for further information about this process. You may also file your complaint with the Secretary of the Department of Health and Human Services at the address below. All complaints must be submitted in writing or by email. You will not be penalized for filing a complaint.

Region IX
Office of Civil Rights
US Dept of Health & Human Services
50 United Nations Plaza, Room 322
San Francisco, California 94102
Email address: OCRComplaints@hhs.gov