HIPPA Statement

Notice of Privacy Practices

Effective Date: April 14, 2003

This notice describes how information about your participation at Five Acres may be used and disclosed and how you can get access to this information. This includes your health, mental health and other personal information. Please review it carefully.

If you have any questions about this notice, please contact the Privacy Officer. Click here

Who Will Follow This Notice:
This notice describes Five Acres’ practices and that of:

•All professionals and paraprofessionals authorized to enter information into your client chart.

•All departments and programs of Five Acres.

•All employees, staff, interns, volunteers or members of volunteer groups working at Five Acres.

Our Pledge Regarding Your Personal Information:
Five Acres creates a record of the treatment and services you and/or your child receives here. The information contained in this record is necessary to provide you with quality care and to comply with certain legal requirements. We understand that your health/mental health information is personal and we are committed to protecting information about you and/or your child.

Individually identifiable information about your past, present, or future health or condition, the provision of health/mental health services to you, or payment for services is considered “Protected Health Information (PHI).” Whenever possible, the PHI contained in your record (or your child’s record) remains private. In some circumstances, it is necessary for Five Acres to share some of the PHI contained in your record (or your child’s record). In all but certain specified circumstances, we will share only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.

This notice applies to all of the records of your care generated by Five Acres and will tell you about the ways in which we may use and disclose health/mental health information about you and/or your child. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure health/mental health information that identifies you is kept private

•Give you this notice of our legal duties and privacy practices with respect to health/mental health information about you; and

•Follow the terms of the notice that is currently in effect.

How We May Use and Disclose Information About You:
The following categories describe different ways that we use and disclose your health/mental health information. For each category, we explain what we mean, and offer an example. In some instances a written authorization signed by you is required in order for Five Acres to use or disclose your information; in others it is not. We have tried to identify which instances do not require your signed authorization and which do.

Uses and Disclosures of Health/ Mental Health Information For Which No Signed Authorization is Required

For Treatment: We may use/disclose health/mental health information about you (or your child) to provide you with mental health treatment or services. We may disclose health/mental health information about you (or your child) to professionals or paraprofessionals who work for, or volunteer at, Five Acres and are involved in your treatment or services. For example, your social worker may need to share information about you (or your child) with a DCFS Children’s Services Worker in order to assist you with obtaining needed resources. Different departments or programs of Five Acres also may share information about you in order to coordinate your treatment. For example, our Residential Treatment program may need to share information with our Therapeutic School if your child is receiving services from both. Nevertheless, in all cases, only the minimum necessary information will be shared.

For Payment: We may use/disclose your (or your child’s) health/mental health information in order to bill and collect payment for services you receive at Five Acres. For example, we may need to provide information about your diagnosis and the type of services you (or your child) are receiving to the County of Los Angeles Department of Mental Health in order to be reimbursed for services.

For Quality Assurance / Health Care Operations: We may use/disclose your (or your child’s) health/mental health information in the course of operating our programs. These uses and/or disclosures are necessary to ensure that Five Acres runs properly and that all of our clients receive high quality care. For example, your case may be discussed with clinic staff for review and quality assurance purposes. Your information may be reviewed to evaluate the effectiveness of treatment, or to ensure agency compliance with funding requirements.

Appointment Reminders: We may use/disclose your (or your child’s) health/mental health information to contact you as a reminder that you have an appointment. For example, if you (or your child) have an appointment with a social worker, our support staff may contact you as a reminder. If you do not wish us to contact you for appointment reminders, please provide the Privacy Officer with alternative instructions (in writing).

When Required by Law: We may use/disclose your (or your child’s) health/mental health information when a law requires that we report information about suspected child, elder or dependent adult abuse or neglect; or in response to a court order. We must also disclose information to authorities that monitor compliance with these privacy requirements.

To Avert Threat to Health or Safety: In order to avoid a serious threat to your (or your child’s) health or safety, or the health and safety of the public or another person, we may use/disclose health/mental health information to inform someone who can reasonably prevent or lessen the threat of harm. For example, if a client is threatening to harm him/herself, we might notify family members who might help keep them safe, or hospital personnel who might evaluate the client for potential psychiatric hospitalization.

Judicial and Administrative Proceedings: We may disclose your health/mental health information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials: We may disclose your (or your child’s) health/mental health information to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena.

Specialize Government Functions: We may disclose you (or your child’s) health/mental health information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

For Research Purposes: In certain circumstances, we may use/disclose your (or your child’s) health/mental health information to our research staff and their designees in order to assist psychiatric/psychological research. If you would like this use/disclosure to be limited, please inform the Privacy Officer of this in writing.

Fundraising activities: We may use health/mental health information about you to contact you and inform you about Five Acres fundraising activities. If you do not wish to be contacted about fundraising activities, please inform the Privacy Officer of this in writing.

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

As required by law: We may use and disclose your (or your child’s) health/mental health information when required to do so by any other law not already referred to in the preceding categories.

Uses and Disclosures of Health/ Mental Health Information For Which a Signed Authorization is Required: For uses and disclosures of health/mental health information beyond the areas noted above, we must obtain your written authorization. Authorizations can be revoked at any time to stop future uses/disclosures (except to the extent that we have already acted upon your authorizatio

Your Rights Regarding Your (or Your Child’s) Information:
You have the following rights regarding health/mental health information we maintain about you (or your child):

Right to Inspect and Copy: You have the right to inspect and copy your (or your child’s) health/mental health information upon your written request. However, some mental health information may not be accessed for treatment reasons and for other reasons pertaining to California state law regarding confidentiality of mental health information. We will respond to your written request to inspect records within 5 working days of receiving your request. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you would like copies of your health/mental health information, we must provide the copies within 15 days of receiving your request. No charges for copying, mailing and related expenses will apply. You have the right to choose what portions of your information you want copied and to have prior information on the cost of copying.

Right to Request Restrictions: You have the right to ask that we limit how we use or disclose your health/mental health information. We will consider your request, but are not legally required to agree to the request. If we do agree to your request, we will put it into writing and comply with it except in emergency situations. We cannot agree to limit uses and/or disclosures that are required by law

To request restrictions, you must make your request in writing to: Privacy Officer, Five Acres, 760 W. Mountain View St, Altadena, CA 91001. In your request, you must tell us (1) what information you wish to limit; (2) whether you wish to limit our use, disclosure or both: and (3) to whom you want the limits to apply.

Right to Amend: If you believe that there is a mistake or missing information in our record of your health/mental health information, you may request, in writing, that we correct or add to the record. We will respond to your request within 60 days of receiving it. To request to amend the record, submit the request in writing to: Privacy Officer, Five Acres, 760 W. Mountain View St, Altadena, CA 91001.

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 to amend information that

• Was not created by us
• Is not part of the information kept by our agency;
• Is not part of the information which you would be permitted to inspect and copy;
• Is accurate and complete.

Right to an Accounting of Disclosures: You have a right to get a list of when, to whom, for what purpose, and what content of your (your child’s) health/mental health information has been disclosed. This applies to disclosures other than those made for purposes of treatment payment, or health care operations. To request this list, please submit your request, in writing, to: Privacy Officer, Five Acres, 760 W. Mountain View St, Altadena, CA 91001. Your request must state a time period (which may not be longer than six [6] years and may not include dates before April 14, 2003). We will respond to your request within sixty (60) days of receiving it. The first list you request within a 12 month period will be free. There may be a charge for more frequent lists. In such a case, we will notify you of the cost involved and you may choose to change or withdraw your request before any costs are incurred.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health/mental 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: Privacy Officer, Five Acres, 760 W. Mountain View St, Altadena, CA 91001. Please specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to a Copy of this Notice: You have a right to receive a 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. You may obtain a paper copy of this notice by asking your therapist, or by asking our support staff for a copy. You may also obtain a copy of this notice at our website, www.5acres.org.

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 health/mental health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at Five Acres main campus. The notice will contain the Effective Date on the first page in the top, right-hand corner. In addition, each time a case is opened for you, or your child, at Five Acres, we will offer you a copy of the current notice in effect.

Complaints:
If you think that your privacy rights have been violated, you may file a complaint with the Privacy Officer, Five Acres, 760 W. Mountain View St, Altadena, CA 91001-4996. All complaints must be in submitted in writing. You may also file a complaint with the Secretary of the United States Department of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201. You will not be penalized for filing a complaint.