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.
Notice of Privacy Practices
Bridges..A Community Support System, Inc.
It is important to read and understand this Notice of Privacy Practices before signing the Consent and Acknowledgment Form.
If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Bridges.
Bridges, A Community Support System, Inc.
Terri Eblen, Privacy Officer
949 Bridgeport Avenue, Milford, CT 06460
203-878-6365 ext. 311
Notice of Privacy Practices
Effective Date: April 14, 2003 and Revised February 17, 2010
Purpose of the Notice of Privacy Practices
This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information that we may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information.
Your “protected health information” is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.
We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information and to abide by the terms of the Notice that is currently in effect. However, we may change our notice at any time. The new revised Notice will apply to all of your protected health information maintained by us. You will not automatically receive a revised Notice. If you would like to receive a copy of any revised Notice you should access our web site at www.bridgesmilford.org, contact Bridges or ask at your next appointment.
How We May Use or Disclose Your Protected Health Information
Bridges will ask you to sign a consent form that allows Bridges to use and disclose your protected health information for treatment, payment and health care operations. You will also be asked to acknowledge receipt of this Notice.
The following categories describe some of the different ways that we may use or disclose your protected health information. Even if not specifically listed below, Bridges may use and disclose your protected health information as permitted or required by law or as authorized by you. We will make reasonable efforts to limit access to your protected health information to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the protected health information to the minimum amount necessary to the extent practical to accomplish the intended purpose of any use, disclosure or request for protected health information in a “limited data set” and to the extent such use or disclosure is limited by law.
When We May Not Use or Disclose Your Protected Health Information
Except as described in this Notice, or as permitted by Connecticut or Federal law, we will not use or disclose your protected health information without your written authorization.
Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, Bridges may condition treatment on the provision of an authorization, such as for research related to treatment. If you do authorize us to use or disclose your protected health information for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting Bridges’s Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization.
A signed authorization or court order is required for any use or disclosure of psychotherapy notes except to carry out certain treatment, payment, or health care operations and for use by Bridges for treatment, for training programs, or for defense in a legal action.
A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by Bridges. If Bridges chose to send out a marketing communication, it shall not accept paymant directly or indirectly.
Your Health Information Rights -You have the following rights with respect to your protected health information. The following describes how you may exercise these rights.
Right to Request Restrictions of Your Protected Health Information – You have the right to request certain restrictions or limitations on the protected health information we use/disclose about you. You may request a restriction or revise a restriction on the use or disclosure of your protected health information by providing a written request stating the specific restriction requested. Bridges cannot use protected health information of payment or health care operations to a health plan if the protected health information subject to restriction pertains solely to a service paid out-of-pocket in full. You can obtain a Request for Restriction form from Bridges. We are not required to agree to your requested restriction. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted protected health information is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and Bridges may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restriction is only effective with respect to protected health information created or received after we have informed you of the termination.
Right to Receive Confidential Communications – You have the right to request a reasonable accommodation regarding how you receive communications of protected health information. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. You may submit a request in writing to Bridges requesting confidential communications. You can obtain a Request for Confidential Communications form from Bridges.
Right to Access, Inspect and Copy Your Protected Health Information – You have the right to access, inspect and obtain a copy of your protected health information that is used to make decisions about your care for as long as the protected health information is maintained by Bridges. To access, inspect and copy your protected health information that may be used to make decisions about you, you must submit your request in writing to Bridges. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing or other supplies associated with your request. You have the right to access in electronic format the current extent of your electronic health record and the fee charged is capped at cost of labor to provide. We may deny, in whole or in part, your request to access, inspect and copy your protected health information under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent health care professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs and attorney’s fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing such rights.
Right to Amend Your Protected Health Information – You have the right to request an amendment to your protected health information for as long as the information is maintained by or for Bridges. Your request must be made in writing to Bridges and must state the reason for the requested amendment. You can obtain a Request for Amendment form from Bridges. 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 written statement disagreeing with the denial. We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.
Right to Receive An Accounting of Disclosures/Breaches of Unsecured Protected Health Information – You have the right to be notified by us or by one of our business associates in the event that unsecured protected health information is breached. In addition, you have the right to request an accounting of certain disclosures of your protected health information by Bridges or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning on or after April 14, 2003 that is within six (6) years from the date of your request. The first accounting provided within a twelve-month period will be free. We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be given the opportunity to withdraw or modify your request for an accounting of disclosures in order to avoid or reduce the fee.
Right to Obtain A Paper Copy of 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 by contacting Bridges. In addition, you may obtain a copy of this Notice at our web site, www.bridgesmilford.org.
Right to Complain – You may file a complaint with us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you.
Terri Eblen, Privacy Officer, Bridges..A Community Support System, Inc, 949 Bridgeport Avenue, Milford, CT 06460 203-878-6365 ext. 311