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Effective: April 14, 2003
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.
Thresholds respects your confidentiality and the privacy of your health information. We release confidential information about you only as required under Illinois and federal law. When we release information, we will not release more information than necessary.
This Notice explains our policies about the use of your records at Thresholds and explains your rights regarding your records and health information. If you have any questions about this Notice, please contact the Privacy Officer at The Thresholds, 4101 North Ravenswood Ave., Chicago, Illinois 60613, Phone – 773/572-5300; E-mail: privacy@thresholds.org.
Use and Disclosure of Personal Health Information
What do we mean by Personal Health Information? Information about your past, present, or future health, treatment, or information about payment for health care services that identifies you personally.
To give you the best care, we may need to share your confidential information with other organizations or persons.
When do we share this information?
· Treatment. We may share information about you to provide, coordinate, or manage your services and care. Example: If you are in more than one Thresholds’ program, those programs will share information to decide which services work best for you.
· Payment. In order to get paid for the treatment and services you received from Thresholds. We will do this only when you tell us we can in writing (we have pre-printed forms to do this). Example: Information provided in billing Medicaid or Medicare .
· Health Care Operations. We may use some information about you to ensure quality service. We may also use information if it is necessary to run Thresholds. Example: Evaluating the program you attend and training our staff.
Sharing Your Information without your Permission. There may be times when we will share information without asking you first. There are laws that say we can or must share information about you without your permission.
When will we do this?
· Emergencies. We may share information as needed to deal with the immediate emergency you are facing. Example: We may tell an ambulance crew what medications you’re taking.
· Follow up Appointments/Care. We may contact you with reminders of future appointments (we will leave appointment information on your answering machine unless you tell us not to). We might also tell you about benefits available to you or give you health-related information you might want to know about.
· To obey the law. This would include:
§ The Court says we have to release information.
§ The law says we must report information about exposure to some contagious diseases, or if we suspect abuse and/or neglect.
§ The Government says so. We may provide necessary health information to governmental agencies for audits, investigations, inspections, and licensure. If the U.S. Department of Health and Human Services asks for information to determine if we are obeying federal laws related to health care, we must give them that information. We will also give information to government agencies that pay for our services.
§ We must give health information to coroners, medical examiners, or funeral directors so that they can do their jobs.
§ We must provide health information regarding military personnel and veterans to the government in some situations.
§ Sometimes we must provide health information to government agencies regarding those agencies’ responsibilities. Examples: We may provide information about you to: jails or prisons if you are or were in jail or prison, the Census Bureau, and agencies ensuring national security.
Research. We may share information with our research staff , but only if Thresholds has formally approved the research. Thresholds will approve research only if the Research Department has proven that your medical information will be kept private.
Criminal Activity or Danger to Others. If a crime is committed on our property or against our personnel, we may share information with law enforcement so they can catch the criminal. We may also call the police or sheriff when we think someone is in immediate danger.
Fundraising. Because we are a not-for-profit agency, we need help in raising money. We may contact you for a donation.
Your Rights Regarding Your Personal Health Information
The law says you have the following rights:
· Restrict your Record. You have the right to ask that we limit how we use and share your confidential information. If you want to do this, you must write us and tell us. You must address your letter to the Thresholds Privacy Officer and send it to the address at the beginning of this notice. In your letter you must tell us:
· What information you want to limit;
· If you want to limit how Thresholds’ uses your information internally, what we share with others, or both; and
· To whom you want the limits to apply.
Thresholds is not required to follow your request if we believe it is in our best interest to allow the use and sharing of the information.
· Copy your record. You have the right to look at or get copies of your records that we have. Again, you must make the request in writing to the Thresholds Privacy Officer. If we don’t have your information but know who does, we will tell you how to get it. We will respond to your request within 30 days. Sometimes we may deny your request. If we do, we will tell you in writing what our reasons are for the denial and how you can appeal the denial. We may charge you a reasonable fee for copying and mailing the documents you request.
· Release your record. You may agree in writing to the release of any portion of your record to others for any purpose you choose. We have pre-printed forms you may use, or you may write your request without using our form. Give the written request to a staff person in your program. If you give us permission to use or disclose your confidential information, you may withdraw or cancel that permission, in writing, at any time. If you withdraw your permission, we may no longer use or disclose confidential information about you for the reasons you stated in your written authorization. You understand that we are unable to take back any disclosures we have already made before you withdrew your permission.
· Amend your record. If you believe that there is a mistake in your record or that a piece of information is missing, you have the right to request that we correct or add to the record. The request must be in writing. You can write to the Thresholds Privacy Officer and asked for a Request to Amend Health Information form. You may use this form or you may write your own request. We will respond within 60 days of receiving your request. We may turn down your request if we determine that the record is: 1) correct and complete; 2) not created by Thresholds, 3) a record you are not allowed to look at or have copies of, or 4) not part of our records. If we turn you down, we will write to you to tell you the reasons for the denial. We will also tell you how to file a written statement of disagreement with the denial. If you do this, we must respond. Your statement of disagreement and our response will be added to your record. If we approve the request for amendment, we will change the record and let you know we made the change. We will also tell anyone else who needs to know about the change.
· Accounting of disclosures. You have the right to get a list of instances when we’ve disclosed your confidential information. This list will not include uses or disclosures that:
· you’ve already agreed to,
· we used for treatment, payment, or health care operations, or
· we shared with you or your family.
It also excludes information we are required to release. Example: We don’t have to tell you when we release information for national security purposes, to law enforcement officials, or correctional facilities. You can request a list of disclosures we made after April 14, 2003, and during a specified amount of time, but not more than six years. Example: You may request a list of organizations and persons we disclosed your information to between April 15, 2003, and March 31, 2005.
Please submit you request in writing to the Thresholds Privacy Officer. We will respond to your written request within 60 days of receiving it. We will notify you of the cost involved in preparing this list.
· Contacting you. You have the right to ask that we send information to you at any address you choose. You can also say how we can contact you. Example: You can ask that we contact you only by phone or e-mail. If you want to do this, you must put it in writing and give it to a staff person at the program where you receive services. We can turn down the request, but we will always agree to it if it is reasonable.
· Questions and Complaints. If you have questions or complaints about our privacy practices or want to get a copy of this Notice of Privacy Practices write to the Thresholds Privacy Officer. You may also get a copy of this notice at our website, http://www.thresholds.org. Even if you request an e-mail copy of this notice or read it on the web, you’re always entitled to a paper copy. You may also file a complaint with the United States Secretary of Health and Human Services. We will not retaliate against you for filing a complaint with Thresholds or anyone else about any practice, policy, or action.
We reserve the right to change this Notice and our privacy practices. We will only do this when it is in the best interest of Thresholds or when we need to change them in order to obey with the law. If we change our privacy practices we will also change this Notice. Whenever we change this Notice, we will post a copy of the new Notice at all Thresholds locations and will update our web site. You may request a printed copy of the current notice any time you want by contacting the Thresholds Privacy Officer.
Further information. You may have additional rights under other applicable laws. For additional information, please contact the Privacy Officer.
Effective date: 04/14/03
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