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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.
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