Effective Date:  April 14, 2004

NOTICE OF PRIVACY PRACTICES

(45 CFR §164.520(a))

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

The privacy of your personal and health information is important.  This requires no action on your part unless you have a request or complaint.  If you have any questions about this notice, please contact a Four Rivers’ Privacy Officer at (812) 847-2231.

WHO WILL FOLLOW THIS NOTICE

This notice describes our practices and that of:

Ø      Any health care professional authorized to release information for a specific employment purpose.

Ø      All departments and units of Four Rivers.

Ø      All employees, staff and other personnel of Four Rivers Resource Services, Inc.

Ø      Any member of a volunteer group we allow to help you at Four Rivers.

Ø      All these entities, sites and locations follow the terms of this notice.  In addition, these entities, sites and locations may share information with each other for services, payment or Four Rivers operations purposes described in this notice.

OUR PLEDGE REGARDING INFORMATION

We understand that information about you and your health is personal.  We are committed to protecting information about you.  We create a record of the services you receive and/or of your employment at Four Rivers.  We need these records to provide you with quality services or employment and to comply with applicable federal and state laws.  This notice applies to all of the records of your services or employment generated by and for Four Rivers.  Other agencies/facilities/organizations may have different policies or notices regarding use and disclosure of your information.

This notice will tell you about the ways in which we may use and disclose information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of the information.

We are required by law to:

·         make sure that information that identifies you is kept private;

·         give you this notice of our legal duties and privacy practices with respect to information about you; and

·         follow the terms of the notice that is currently in effect.

HOW WE ARE REQUIRED BY LAW TO DISCLOSE INFORMATION ABOUT YOU

Ø      As Required By Law.  We will disclose information about you when required to do so by federal, state or local law.

Ø      To Avert a Serious Threat to Health or Safety.  We will use and disclose information about you when we have a “Duty to Report” under state or federal law; because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat.

Ø      Public Health Risks.  We will disclose information about you for public health reporting required by federal or state law.  These activities generally include the following:

·         to prevent or control disease, injury or disability;

·         to report births and deaths;

·         to report child abuse or neglect;

·         to report reactions to medications or problems with products;

·         to notify people of recalls of products they may be using;

·         to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

·         to notify the appropriate government authority if we believe a consumer or employee has been the victim of abuse, neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

Ø      Health Oversight Activities.  We will disclose information as required by law to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections and licensure.  These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Ø      Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we will disclose information about you when properly ordered to do so by a court.

Ø      Law Enforcement.  We will release information if asked to do so by a law enforcement official and if permitted by law:

·         in response to a court order;

·         if required by state or federal law;

·         to identify or locate a suspect, fugitive, material witness or missing person;

·         about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;

·         about a death we believe may be the result of criminal conduct;

·         about criminal conduct at a Four Rivers facility; and

·         in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Ø      Protective Services for the President and Others.  We will disclose information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose information.  For each category of uses or disclosures we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Ø      For Treatment.  We may use information about you to provide you with services.  We may disclose information about you to other Four Rivers personnel who are involved in providing you with services.  Different departments of the Four Rivers may share information about you in order to coordinate the different things you need.

Ø      For Payment.  We may use and disclose information about you so that the services you receive at Four Rivers may be billed to and payment may be collected from you, an insurance company or a third party.  For example, we may need to give your health plan information about services that you received at Four Rivers so your health plan will pay us or reimburse you for your services.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Ø      For Health Care and Employment Operations.  We may use and disclose information about you for Four Rivers’ operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan.  These uses and disclosures are necessary to run Four Rivers Resource Services, Inc. and make sure that all of our consumers and employees receive quality services or employment.  For example, we may use information to review our services and to evaluate the performance of our staff in serving you.  For our employees, the information may be used to review our group benefits and to administer our employment policies and procedures.  We may also combine information about many consumers to decide what additional services that Four Rivers should offer, what services are not needed and whether certain new services are effective.  We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students and other personnel for review and learning purposes.  We may also combine the information we have with information from other agencies/organizations/facilities to compare how we are doing and see where we can make improvements in the services or benefits that we offer.  We may remove information that identifies you from this set of information so others may use it to study without knowing who the specific consumers or employees are.

Ø      Meeting Reminders.  We may use and disclose information to contact you as a reminder that you have a meeting at Four Rivers Resource Services, Inc.

Ø      Treatment Alternatives.  We may use and disclose information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Ø      Health-Related Benefits and Services.  We may use and disclose information to tell you about health-related benefits or services that may be of interest to you.

Ø      Fundraising Activities.  We may use information about you to contact you in an effort to raise money for Four Rivers Resource Services, Inc. and its operations.  We may disclose information to a foundation related to Four Rivers so that the foundation may contact you in raising money for Four Rivers.  We only would release contact information, such as your name, address and phone number and the dates you received services at Four Rivers.  If you do not want Four Rivers to contact you for fundraising efforts, you must notify in writing the Four Rivers’ location where you receive services.

Ø      Individuals Involved in Your Care or Payment for Your Care.  We may release certain limited information about you to a friend or family member who is involved in your care.  We may also give information to someone who helps pay for your care.  We may also tell your family or friends your condition.  In addition, we may disclose information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

SPECIAL SITUATIONS

Ø      Organ and Tissue Donation.  If you are an organ donor, we may release information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Ø      Military and Veterans.  If you are a member of the armed forces, we may release information about you as required by military command authorities.  We may also release information about foreign military personnel to the appropriate foreign military authority.

Ø      National Security and Intelligence Activities.  We may release information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Ø      Workers' Compensation.  We may release health information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Ø      Coroners, Medical Examiners and Funeral Directors.  We may release information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release information about consumers and/or employees of Four Rivers to funeral directors as necessary to carry out their duties.

Ø      Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official.  This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING INFORMATION ABOUT YOU

You have the following rights regarding information we maintain about you:

Ø      Right to Inspect and Copy.  You have the right to inspect and copy information that may be used to make decisions about your services or employment.  Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy information that may be used to make decisions about you, you must submit your request in writing on the “Request for Access to Consumer/Employee File” form to the Four Rivers’ location where you receive services or for employees to the Four Rivers Regional Office.

We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to information, under some circumstances you may request that the denial be reviewed.  Another licensed health care professional chosen by Four Rivers will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

Ø      Right to Amend.  If you feel that information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for Four Rivers.

To request an amendment, your request must be made in writing on the “Request for Amendment” form and submitted to the Four Rivers’ location where you receive services or for employees to the Four Rivers Regional Office.  In addition, you must provide a reason that supports your request.

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 if you ask us to amend information that:

·         was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

·         is not part of the medical information kept by or for the hospital;

·         is not part of the information which you would be permitted to inspect and copy; or

·         is accurate and complete.

If your request is accepted you will be notified in writing on the “Acceptance of Request for Amendment” form.  If your request is denied you will also receive that information in writing on the “Denial of Request for Amendment” form.

Ø      Right to an Accounting of Disclosures.  You have the right to request an “Accounting of Disclosures.”  This is a list of the disclosures we made of information about you.

To request this list or accounting of disclosures, you must submit your request in writing to the Four Rivers’ location where you receive services or for employees to the Four Rivers Regional Office.  Your request must state a time period, which may not be longer than 6 years and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper, electronically).  The first list you request within a 12-month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Ø      Right to Request Restrictions.  You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment or operations.  You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a specific treatment session that you had.

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing on the “Request for Restrictions on Uses and Disclosures” form to the Four Rivers’ location where you receive services or for employees to the Four Rivers Regional Office.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your parents.

Ø      Right to Request Confidential Communications.  You have the right to request that we communicate with you about 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 the Four Rivers’ location where you receive services or for employees to the Four Rivers Regional Office.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.

Ø      Right to a Paper Copy of This Notice.  You have the right to a paper 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 copy of this notice at our web site, www.frrs.org.

To obtain a paper copy of this notice, ask any Four Rivers’ staff person.

CHANGES TO THIS NOTICE

Ø      We reserve the right to change this notice as needed but will be formally reviewed and revised at least every three (3) years.  Input will be solicited in staff meetings.  This input will be submitted to and discussed by the Services Teams.  Finalized recommendations will be submitted to the FRRS Board of Directors for approval.  We reserve the right to make the revised or changed notice effective for 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 in each of our locations.  The notice will contain on the first page, in the top right-hand corner, the effective date.  In addition, each time you enroll with Four Rivers for services or are re-hired, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Four Rivers Resource Services, Inc. or with the Secretary of the Department of Health and Human Services.  To file a complaint with Four Rivers Resource Services, contact a Four Rivers’ Privacy Officer at PO Box 249, Linton, IN, 47441.  To file a complaint with the Secretary of the Department of Health and Human Services, residents of Indiana are in Region V; contact the Office of Civil Rights, US Department of Health and Human Services, 233 N. Michigan Avenue, Suite 240, Chicago, IL, 60601.  A fact sheet on how to file this complaint is available at www.hhs.gov/ocr/privacyhowtofile.htm or may be requested from a Four Rivers staff person.  All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF INFORMATION

Other uses and disclosures of information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization.   You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the services or employment that we provided to you.

CONTACTS

Four Rivers Resource Services, Inc.

Daviess County                                   Martin County

(812) 254-4471                                   (812) 295-4494

rdidc@frrs.org                                  rdimc@frrs.org

Greene County                                    Sullivan County

(812) 659-2197                                   (812) 268-4371

gcds@frrs.org                                    scarc@frrs.org

Regional Office                                  Community Living

(812) 847-2231                                   (812) 254-3207

fourrivers@frrs.org             communityliving@frrs.org

This notice was developed to ensure our compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Four Rivers supports the effort to protect consumer and employee confidentiality and the security of individual health information.

This policy is adapted from:

·         Notice of Privacy Practices, © 2002 Krieg DeVault LLP

·         © 2001 Krieg DeVault LLP, Locke Reynolds LLP

·         PL 104-10, “Health Insurance Portability and Accountability Act of 1996 (HIPAA)”, Federal Register, Rules and Regulations, Department of Health and Human Services, Office of the Secretary, 45 CFR § 164.520(a), Standard for Privacy of Individually Identifiable Health Information, August 12, 2002

·         Fact Sheet:  How to File a Health Information Privacy Complaint with the office for Civil Rights, www.hhs.gov/ocr/privacyhowtofile.htm, US Department of Health and Human Services, Office of Civil Rights, April 2003

NOTICE OF PRIVACY PRACTICES

(45 CFR §164.520(a))

CONSENT FORM

Our Notice of Privacy Practices provides information about how Four Rivers Resource Services, Inc. (FRRS) may use and disclose Protected Health Information (PHI) about you.  You have the right to review our Notice before signing this consent.  The terms of our Notice may change.  If we change our Notice, you may obtain a revised copy by contacting any Four Rivers’ staff person, or on our web site (www.frrs.org).

You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.  We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and disclosure of PHI about you as described in our Notice of Privacy Practices.  You have the right to revoke this consent in writing, except where we have already made disclosures based on your prior consent.

Reason Given for Refusing to Sign this Notice