Healthy Futures Notice of Privacy Practices - HIPAA FORM 001

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.

Healthy Futures is committed to protecting the confidentiality of your Protected Health Information (PHI) and is required by law to do so. If you have any questions about this Notice please contact: our Privacy Administrator: Rebecca West Dick at (207) 377-5377.

This Notice of Privacy Practice describes how we may use and disclose your protected health information to provide health and wellness services, to receive payment for our services and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including your name, address, and telephone number, health and wellness services provided to you and anything else that could be used to identify you.

We are required to abide by 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 protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website (www.healthyfuturesmaine. org), calling the office and requesting a revised copy or asking for one at the time of your next visit.

1. How Healthy Futures may use and disclose your Protected Health Information

A. Uses and Disclosures of Protected Health Information without Authorization Needed

Your protected health information may be used and disclosed by your Health Advocate or our office's staff for the purpose of providing health and wellness services to you. Your protected health information may also be used and disclosed for Healthy Futures to receive payment from your health insurer for your participation in the Healthy Futures program.

Following are examples of the types of uses and disclosures of your protected health information that Healthy Futures is permitted to make without written authorization. These examples are meant to describe the types of uses and disclosures that may be made by our office.

Health and Wellness Services: We will use and disclose your protected health information to coordinate your health care and any related services with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose your protected health information to physicians, physician assistants, nurse practitioners, and any providers who may be treating you when we have the necessary permission from you to disclose your protected health information.

Payment: Your protected health information will be used as needed, for Healthy Futures to be paid for your health and wellness services from your health insurance provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health and wellness services we provide for you, such as; making a determination of eligibility or coverage for insurance benefits and undertaking utilization review activities.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our office. We may call you by name when you visit our office. We may use or disclose your protected health information to contact you to set up or confirm a visit.

We may use or disclose your protected health information, as necessary, to provide you with information about health-related information, programs and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about Healthy Futures and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Administrator to request that these materials not be sent to you. We will not disclose your information to any outside entity that would engage in any marketing, telemarketing or sales.

B. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time.

C. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. (Request HIPAA FORM 005) If you are not present or able to agree or object to the use of disclosure of the protected health information, then your Health Advocate may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others Involved in Your Health and Wellness: Unless you object, we may disclose to a member of your family or any other person you identify, your protected health information that directly relates to that person's involvement in your health and wellness. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person of your location or general condition. Finally, we may use or disclose your protected health information 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 and wellness.

Emergencies: Emergencies rarely happen during a visit with Healthy Futures. If one occurs, we may use or disclose your protected health information to assist emergency medical personnel to provide emergency treatment.

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

D. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose protected health information for public heath activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may share protected health information with a government agency that oversees the Facility or its staff, such as the State Department of Health & Human Services, the federal agencies that oversee Medicare, the Board of Medical Examiners or the Board of Nursing. These agencies need protected health information to watch how well we follow state and federal laws.

Abuse or Neglect: We may disclose your protected health information to a public authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws and codes.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biological deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Public Safety: We may share protected health information for public safety purposes in limited circumstances. We may share protected health information to law enforcement officials in response to a search warrant or a grand jury subpoena. We may share protected health information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, and to report criminal conduct at the facility. We may share your protected health information to law enforcement officials and others to prevent a serious threat to health or safety.

Research: We will not disclose your protected health information to researchers. Healthy Futures may share statistical information about its participant population, but not in a way that individuals are identifiable.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your protected health information as required by military command authorities or to the Department of Veterans Affairs. We may share protected health information with federal officials for intelligence and national security purposes, or for presidential Protective Services.

2. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

A. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that Healthy Futures uses for making decisions about you.

B. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operation. You may also request that any part of your protected health information not be disclosed to family members or friends for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your Health Advocate is not required to agree to a restriction that you may request. If your Health Advocate believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your Health Advocate does agree to the requested restriction, we may not use or disclose your protected 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 Health Advocate. You may request a restriction by filling out the appropriate Restriction of Protected Health Care Information form. Request HIPAA FORM 005.

C. You have the right to request to receive confidential communications 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 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 to our Privacy Administrator. Request HIPAA FORM 014.

D.You may have the right to have your Health Advocate amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an 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 Administrator to determine if you have questions about amending your medical record. Request HIPAA FORM 006

E. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than services, payment or healthcare operations as described in this Notice of Privacy Practices. It also excludes disclosures we may have made to you, family members or friends for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. Request HIPAA FORM 011.

F. 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.

3. Do you have concerns or complaints?
Please tell us about any problems or concerns you have with your privacy rights or how we use or share your medical information. If you have a concern, please contact the Privacy Administrator. If for some reason we cannot resolve your concern, you may also file a complaint with the federal government at:

Office for Civil Rights
U.S. Department of Health & Human Services
JFK Federal Building - Room 1875 Boston, MA 02203
(617) 565-1340; (617) 565-1343 (TDD); (617) 565-3809 FAX

We will not penalize you or retaliate against you in any way for filing a complaint with the federal government.

You may contact our Privacy Administrator, Rebecca West Dick at (207) 377-5377 for further information about the complaint process.

This notice was published as of February 6, 2008.