InterCommunity Mental Health Group


281 Main Street East Hartford, Connecticut 06118		(860) 569-5900 development@icmhg.org

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of the Capital Area

PRIVACY NOTICE

InterCommunity Mental Health Group, Inc.
NOTICE OF PRIVACY PRACTICES Effective Date: April 1, 2003

THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

ICMHG is required by law to maintain the privacy of your health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; and to abide by the terms of the Notice that are currently in effect. Information regarding your healthcare is protected by state law and two federal laws: HIPAA, 42 U.S.C SS. 1320d et seq., 45 C.F.R. Parts 160 & 164 and the confidentiality Law, 42 U.S.C. SS 290dd-2, 42 C.R.F. Part 2.

I. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to ICMHG. You have the right to:

Access to Personal Health Information.

You have the right to inspect and obtain a copy of your clinical or billing records or other written information, with some exceptions. Your request must be made in writing. We may charge a reasonable fee for our costs.. We may deny your request to inspect or receive copies in certain circumstances. If you are denied access to health information, in some cases you have a right to request review of the denial. Request Restrictions. You have the right to request restrictions on our use of your health information for treatment, payment, or health care operations. You also have the right to request restrictions on the information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. We are not required to agree to your requested restriction except that you may restrict disclosures to family members or friends.
Request Amendment.

You have the right to request amendment of your health information maintained by ICMHG for as long as the information is kept by or for ICMHG. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment in certain circumstances. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a statement disagreeing with the denial.
Request an Accounting of Disclosures.

You have the right to request an "accounting" of certain disclosures of your health information. This is a listing of disclosures made by ICMHG or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosure made according to your Authorization, and certain other exceptions. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.

II. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

III. USES AND DISCLOSURES WITHOUT AUTHORIZATION: TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following lists various ways in which we may use or disclose your health information for purposes of treatment, payment and health care operations.

For Treatment.

We will use your health information in providing you with treatment and services and may disclose information to other providers involved in your care. We may provide your health information to clinicians, doctors and other persons involved in your care. For example, we will contact your physician to discuss your plan of care.
For Payment.

We may use and disclose your health information for billing and payment purposes. We may disclose your health information to an insurance or managed care company, Medicare and Medicaid. For example, we may contact Medicare to confirm your coverage.
For Health Care Operations.

We may use and disclose your health information as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor our quality of care. For example, health information of clients may be combined and analyzed for purposes such as evaluating and improving quality of care.
IV. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

We may use your information in certain situations based on law and regulations to include: emergencies, disaster relief or to avert a serious threat to the safety of others; as required by law; to Business Associates; for public health oversight activities; for reporting victims of abuse, neglect or domestic violence; legal proceedings; certain law enforcement activities; Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations; Military, Veterans and other Specific Government Functions.; and Workers' Compensation. We may use or disclose health information to remind you about appointments. If we participate in research, we would request your authorization.

We will not disclose health information about you to a family member, close personal friend or clergy, who is involved in your care, without your written permission.

V. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION

For disclosures concerning psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. Except as specifically permitted or required under state or federal law, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization.

VI. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact your Case Coordinator. If you believe that your privacy rights have been violated, you may file a complaint in writing with ICMHG. We will not retaliate against you if you file a complaint.

To file a complaint with ICMHG, contact:
Ann Gueutal, Privacy Officer
281 Main Street
East Hartford, CT 06118
(860) 569-5910

You may also file a complaint in writing with:
U.S. Department of Health and Human Services
Office of the Secretary
200 Independence Avenue, S. W.
Washington, D. C. 20201
(202) 619-0257 or Toll Free 1-877-696-6775

VIII. CHANGES TO THIS NOTICE

We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by ICMHG as well as for all health information we receive in the future. We will provide a copy of the revised Notice upon request. InterCommunity Mental Health Group, Inc.

To print the following, click here

NOTICE OF PRIVACY PRACTICES Effective Date: April 1, 2003 I _______________________________________ received a copy of the InterCommunity Mental Health Group, Inc. Client Privacy Notice this date.
___________________________________________	____________
Client Name	Date
___________________________________________	____________
Employee Name	Date
Special Notes: ____ Translator required ____ Client chose not to sign ____ Other: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
Place in Clinical Record – Section: Outgoing You will not be retaliated against for filing a complaint.
If you believe InterCommunity Mental Health Group has violated your privacy rights, you may file a complaint or contact the Department of Health and Human Services Region I – Office of Civil Rights J.F.K. Federal Building Room 1875, Boston MA 02203

Funded in part by: State of Connecticut Department of Mental Health and Addiction Services, and the municipalities and communities we serve.
© InterCommunity Mental Health Group, Inc. _____ Site Designed by Janet Boyd