Notice of Privacy Practices

"To assist people whose lives have been disrupted by mental illness to lead vocationally productive and socially satisfying lives in our community"

As a psychiatric rehabilitation agency we promote recovery-oriented practice in Suffolk County through advocacy, community education, and direct services. In order to fulfill this mission we must maintain a commitment to ensure that all individuals who are involved in our services are treated with respect and that all information is treated with the utmost confidentiality and privacy. As such this notice is designed to inform you about Clubhouse’s Privacy Practices. Our employees, staff and all office personnel follow these privacy practices.

We are required by law to maintain the privacy of your medical information and to provide you with notice of our legal duties and privacy practices. This notice will describe how we may use and disclose information that is called "protected health information" (PHI). PHI is any information - oral, recorded, or demographic - that may identify you (i.e. name, address, diagnosis), or that may relate to your past, present or future physical, mental health or condition, and related health care services. We will also outline your rights and our obligations regarding the use and disclosure of that information.

Clubhouse of Suffolk is required to abide by the terms of this Notice of Privacy Practices, which go into effect as of

We may change the terms of our notice, at any time. Any changes to this notice will be posted at Clubhouse of Suffolk sites and will be available on our website:

Permitted Uses:

Treatment

We may use protected health information about you to better serve your rehabilitation treatment and service needs. We may disclose this information in an attempt to coordinate or manage your care and any related services. This may include sharing information with other mental health or community providers to better assist you in achieving your personal goals. For example you may ask for some assistance with securing housing, organizing your benefits or perhaps finding new clinical resources. With your permission we would share information in an attempt to assist you with securing the services you need. It is also important for you to be aware that at times your case record may be reviewed as part of an on-going process to ensure that Clubhouse of Suffolk is providing quality service and care. Specific agency staff are assigned to review records as part of Quality Management and they may have access to your record in an attempt to verify that agency standards are being met and that we are in compliance.

Payment

Clubhouse of Suffolk may disclose protected health information about you in order to obtain payment for health care services. For example, we may need to give your health plan information about a service, your diagnosis, your name/address, or type of treatment received in order to secure payment from your insurance. We may also need to tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose health information about you for agency operations. These uses and disclosures are necessary to run the agency and to make sure that you and other individuals involved with Clubhouse receive quality care. For example, we may use your health information to evaluate the performance of our staff in caring for you. We may also share PHI with our attorneys, consultants and others in order to ensure that Clubhouse is in compliance with the laws that affect us.

Clubhouse of Suffolk may use your Protected Health Information without written consent in the following circumstances:

Clubhouse may use PHI in an effort to notify you or remind you about an upcoming or scheduled appointment for services.

In an effort to provide you with the most comprehensive rehabilitation services available we may discuss with you possible rehabilitation or treatment options/alternatives or health-related products or services that may be of interest to you. We may also use or disclose health information about you in a way that does not personally identify you or reveal who you are.

In addition, we may use or disclose PHI about you without your permission in the following special situations.

• Serious Threat to Health or Safety We may use and disclose protected health information 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.



• Required By Law We will disclose health information about you when required to do so by federal, state or local law.



• Workers' Compensation We may release protected health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.



• Public Health Matters We may be required to report your health information to authorities to help prevent or control disease, injury, or disability. This may require Clubhouse to report information about births, deaths, or suspected child/elder abuse or neglect.



• Health Oversight Activities We may disclose health information to individuals/agencies for the purpose of audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor Clubhouse and ensure compliance with government and civil rights laws.



• Research At this time Clubhouse is not involved in any formal research activities. Should this status change we would notify you that we might use or disclose your PHI for help to conduct research. Any research project would first require approval from Clubhouse’s Board of Directors to ensure that it meets the mission and ethical standards of the agency and is in the best interest of the individuals we serve.



• Military, Veterans, National Security If you are or were a member of the armed forces, or part of the national security we may be asked by military or government authorities to release protected health information about you.



• Law Enforcement /Lawsuits/Court Services We may release protected health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.



• Victims of Abuse, Neglect or Domestic Violence Clubhouse may notify the appropriate government authorities if we believe a client has been the victim of abuse, neglect or domestic violence. We will only make such disclosure if you agree or when required or authorized by law.



• Death/Organ Donation We may release health 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 disclose your health information to people involved with obtaining, storing or transplanting organs or tissue donations.



• Emergencies Clubhouse may use or disclose your protected health information in an emergency situation. If an emergency occurs and treatment is given by law your provider will notify you and attempt to get your authorization as soon as possible. In case of a disaster we may be required to notify the appropriate disaster relief organizations or authorities or family/friends/care givers to keep them aware of your health status, condition or location.



• Family/Friends/Caregivers/Payment Clubhouse may disclose important health information about you to your family member, friend, caregiver, partner, relative, legal guardian or foster parent. We would make every attempt to gain your permission prior to disclosing information, but may need to notify any of the above persons associated with your care in regards to your location, general condition, or death. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person's involvement in your care. You have the right to object to such disclosure at any point in your care/treatment with Clubhouse, again unless there is an emergency.

Other Uses and Disclosures of Health Information

Except for the above outlined areas, Clubhouse of Suffolk would request your written Authorization to release protected health information (PHI). At any time during your rehabilitation treatment or care with Clubhouse you may revoke your Authorization, in writing. If you would like to withdraw your Authorization please contact Paula Fries who will provide you with the necessary paperwork to complete this withdrawal of authorization. Once completed, all written paperwork requests should be mailed to Paula Fries, Privacy Officer and Deputy Director, at P.O. Box 373, Ronkonkoma, NY 11779.

Your Rights

You have the following rights regarding health information we maintain about you:

• Right to Inspect and Copy You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit your request in writing to Clubhouse’s Privacy Officer. If you request a copy of the information, Clubhouse may charge a fee for the costs of copying, mailing or other associated supplies. We may also deny your request to inspect and/or copy your records in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. Please contact Clubhouse’s Privacy Officer, Paula Fries if you have any questions about how to access your records.



• Right to Make Changes If you believe Clubhouse has health information about you that is incorrect or incomplete, you may ask Clubhouse to make changes to correct the information. We ask that you contact Clubhouse’s Privacy Officer in writing and provide as much detail as possible as to what information needs to be changed and why. We may deny your request if you ask us to amend information that Clubhouse did not create, or if Clubhouse believes the information is complete and accurate.



• Right to Accounting of You have the right to request an "accounting of disclosures." This is a list of the



• Disclosures Disclosures we made of health care information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing to Clubhouse’s Privacy Officer. Please include time frames, which may not be longer than six years and may not include dates before April 14, 2003. Clubhouse will review all requests individually and will comply with your request within 60 days, unless circumstances require additional time. Clubhouse may charge a nominal fee for this list if a request is made more than one time annually. You will be notified of all charges prior to completion of your request.



• Right to Request Restrictions You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. You must submit your request in writing to Clubhouse’s Privacy Officer, Paula Fries.



• We are Not Required to Agree to Your Request If we do agree to your request for restrictions, we will comply with your request unless the information is needed to provide you emergency treatment.



• Right to Request Confidential Communications You have the right to request that we communicate with you about Clubhouse services in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. These requests must specify how or where you wish to be contacted. You do not need to give a reason for your request. All reasonable requests must be accommodated. You must submit your request in writing to Clubhouse’s Privacy Officer, Paula Fries.



• Right to a Paper Copy of This Notice 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 it electronically, you are still entitled to a paper copy.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. We will provide you with the address to file your complaint to the U.S. Department of HHS. You will not be penalized for filing a complaint. If you would like to file a complaint with us, please contact Paula Fries, Privacy Officer, P.O. Box 373, Ronkonkoma, NY 11779. All complaints must be in writing.

If you have any questions about this notice, please contact:
Paula Fries, MA ATR-BC CPRP
Privacy Officer/Deputy Director
P.O. Box 373, 939 Johnson Avenue
Ronkonkoma, NY 11779
(631) 471-7242 X314
Fax (631) 471-5150
paula.fries@clubhouseofsuffolk.org