NOTICE OF PRIVACY PRACTICES OF THE FAMILY CONSERVANCY

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.

Our Commitment to Privacy

At The Family Conservancy, we are committed to protecting the privacy of your medical information. In conducting our business, we will create, receive and maintain records relating to you so that we may provide treatment and services to you. Our organization is required by HIPAA to maintain the privacy of certain medical information known as Protected Health Information. HIPAA also requires us to provide you with this Notice explaining our legal obligations and privacy practices, and your legal rights with respect to the Protected Health Information we create, receive and maintain about you. We are required by law to:

Maintain the privacy of your Protected Health Information;
Provide you with this Notice; and
Follow the terms of the Notice that is currently in effect.

We reserve the right to change this Notice at any time in compliance with and as allowed by law. If we change this Notice, the new privacy practices will apply to your information that we already have, as well as to information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new Notice in our offices, have copies available in our offices, and post it on our web site.

The effective date of this Notice is October 15, 2011.

Definition of Terms
In this Notice, we will use terms that have the following meaning:

“Authorization” means a permission form that meets HIPAA requirements for certain disclosures of PHI.
“Disclose” means to release, transfer, give access, provide, or otherwise divulge your Protected Health Information to someone outside of The Family Conservancy.
“HIPAA” refers to the Health Insurance Accountability and Portability Act of 1996 and its regulations.
“Notice” is used to refer to this Notice of Privacy Practices.
“Protected Health Information” or “PHI” means any individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a health plan that relates to:
- Your past, present or future physical or mental health or condition;
- The provision of health care to you; or
- The past, present or future payment for the provision of health care to you.
“We”, “our” or “us” means The Family Conservancy and their individual licensed providers and staff.
“You” means the client who is the subject of the Protected Health Information.

How We May Use or Disclose Your Protected Health Information

Under the law, we may use and disclose your PHI under certain circumstances without your permission. The following categories describe the different ways that we may use and disclose your PHI. These are general descriptions only. They do not cover every example of disclosure within a category.

Treatment: We may use or disclose your PHI for the purpose of providing you with treatment or services, coordinating and consulting about your treatment and care with other health care providers, social service providers and making referrals for services and benefits that you need. We may also disclose your PHI to other practitioners, providers and health care facilities for their use in treating you in the future. For example, if you are transferred to another facility, we may send PHI about you to the facility.

Payment: We may use or disclose your PHI for payment purposes, including for the payment activities of other health care providers or payers. For example, a bill may be sent to you or to a third party payer, including Medicaid, Medicare or another state or federal program. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis and services provided.

Health Care Operations: We may use or disclose your PHI for our health care operations. For example, members of the staff, and/or members of the quality review team may use information in your client record to assess the treatment, services, outcomes and the performance of our staff in caring for you.

Business Associate: We may contract with individuals or entities known as business associates to perform various functions on our behalf or to provide certain services. For example, business associates may provide accounting or legal services. We may disclose your PHI to our business associates so that they can perform the job we’ve asked them to do, but only after they agree in writing with us to implement appropriate safeguards regarding your PHI.

Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical services.

Treatment Alternatives: We may contact you to provide information about service provision, treatment alternatives or other health related benefits that may be of interest to you.

Fundraising: We may contact you as a part of a fundraising effort.

Required by Law: We will use and disclose your PHI as required by federal, state or local law.

Public Health Activities: We may disclose your PHI for public health activities. For example, we may disclose to public health or legal authorities charged with preventing or controlling disease, injury, or disability, to appropriate authorities authorized to receive reports of abuse or neglect, or to notify a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition. Other information that may be disclosed includes PHI related to adverse events with respect to food, supplements, products and product defects or post marketing information to enable product recalls, repairs or replacements.

Abuse, Neglect or Domestic Violence: We may disclose your PHI to the appropriate authority if we believe you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required or authorized by law, we will only make this disclosure if you agree.

Health Oversight Activities: We may disclose PHI to a health oversight agency for health oversight activities authorized by law, including audits, investigations, inspections and licensure, or other activities that are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Judicial and Administrative Proceedings: We may disclose your PHI in the course of a judicial or administrative proceeding.

Law Enforcement: We may disclose your PHI for a law enforcement purpose:As required by law, including reporting wounds or physical injuries;

In response to a court order, subpoena, warrant, summons, administrative request or similar process;
To identify or locate a suspect, fugitive, material witness or missing person;
About the victim of a crime if we obtain the individual’s agreement or, under certain limited circumstances, if we are unable to obtain the individual’s agreement;
To alert authorities of a death we believe may be the result of criminal conduct;
Information we believe is evidence of criminal conduct occurring on our premises; and
In emergency circumstances to report the commission and nature of a crime; the location or victim(s) of such crime; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: We may disclose PHI to coroners, medical examiners and funeral directors as necessary for them to carry out their duties.

Organ and Tissue Donation: We may use or disclose PHI 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.

Research: We may disclose information to researchers when certain conditions have been met as provided by HIPAA.

Serious Threats to Health or Safety: We may use or disclose your PHI to avert a serious threat to health and safety if we, in good faith, believe the use or disclosure is necessary to prevent or lessen the threat and is to a person reasonably able to prevent or lessen the threat (including the target) or is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.

Military and Veterans: If you are a member of the armed forces, we may disclose your PHI as required by military command authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.
Inmate: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the institution or law enforcement official, if the disclosure is necessary (1) for the institution to provide you with health services; (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.

National Security and Intelligence: We may disclose your PHI to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We may also disclose your PHI to federal officials for the purposes of providing protection to the President of the United States, other authorized persons, or foreign heads of state, or to aid special investigations.

Incidental Uses and Disclosures: There are certain incidental uses or disclosures of your PHI that occur while we are providing services to you or conducting our business. We will make reasonable efforts to limit these incidental use and disclosures.

Workers’ Compensation: We may disclose your PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.

To You: When you request, we are required to disclose to you the portion of your PHI that contains medical records, billing records, and any other records used to make decisions regarding your health care. We are also required, when requested, to provide you with an accounting of most disclosures of your PHI, if the disclosure was for reasons other than for treatment, payment, or other healthcare operations, and if the PHI was not disclosed pursuant to your individual Authorization.

To the Secretary: We will disclose your PHI to the Secretary of the Department of Health and Human Services when required to do so.

Other Disclosures

To Others Involved in Your Care: We may disclose your PHI to a relative or other individual whom you have identified as being involved in your health care or payment related to your health care. If you are not present, we will only disclose the information directly relating to the individual’s involvement in your care. We may also use or disclose your PHI to notify a relative or other individual who is responsible for your care of your location, general condition, or death.

Pursuant to an Authorization: Before we may use or disclose your PHI for a reason that is not listed in this Notice or required by law, we are required to obtain an Authorization. You are not required to sign an Authorization. If you choose to sign an Authorization, you may revoke it at any time. Once we receive your revocation, it will only be effective for future uses and disclosures. A revocation will not apply to any information that may have been used or disclosed in reliance on the Authorization and prior to receiving your written revocation.

Personal Representatives: We will disclose your PHI to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc. so long as you provide us with written notice/authorization and any supporting documents (e.g., power of attorney). Note: Under the HIPAA privacy rule, we do not have to disclose information to a personal representative if we have a reasonable belief that:

You have been, or may be, subjected to domestic violence, abuse, or neglect by such person;
Treating such person as your personal representative could endanger you; and
In the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

Your Rights Regarding Your Protected Health Information
You have the following rights with respect to your PHI.

Right to Inspect and Copy: You have the right to inspect and copy your PHI that may be used to make decisions about your care. To inspect your treatment and billing records, you may contact the appropriate The Family Conservancy personnel. To obtain copies of this information, you must submit your request in writing to your clinician, Clinical Director or Clinical Manager, if your clinician is no longer employed by us. If you request a copy of the information, we may charge a fee in advance for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. We will comply with the outcome of the review. You do not have the right to inspect or copy psychotherapy notes or materials compiled in anticipation of litigation or similar proceedings.

Right to Request an Amendment: If you feel the PHI we have in your record 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 The Family Conservancy. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your request for the amendment. We may deny your request if it is not in writing or does not include a reason to support the request. If we deny your request, we will provide you with a written explanation of the reasons and your rights. We may also 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 PHI kept by or for The Family Conservancy;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

Right to an Accounting of Disclosures: You have the right to receive an accounting of certain disclosures of your PHI made by us or our business associates. The accounting will not include (1) disclosures made for purposes of treatment, payment, or healthcare operations; (2) disclosures made to you; (3) disclosures pursuant to an Authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures for national security purposes; (6) disclosures to correctional institutions or law enforcement officials, and (7) disclosures incidental to otherwise permissible disclosures. To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period, which may not be longer than six (6) years prior to the date on which the accounting is requested. Your request should indicate in what form you want the accounting (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists within the same 12-month period, 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.

Right to Request Restrictions: You have the right to request a restriction or limitation on how we use or disclose your PHI for treatment, payment, and healthcare operations. You also have the right to request a limitation on your PHI that we disclose to certain family members or close personal friends identified by you who are involved in your care or the payment of your care. For example, you could ask that we not use or disclose information about a particular evaluation you had. To request restrictions, you must make a request in writing to the Privacy Officer. In your request, you must tell us (1) what information you want to restrict; (2) whether you want to restrict use, disclosure, or both; and (3) to whom you would like the restrictions to apply (for example, disclosure to your spouse). Except as provided in the next paragraph, we are not required to agree to your request. If we do agree to honor your request, we will honor the restriction until you revoke it or we notify you. We will comply with any restriction, except as otherwise required by law, if (1) the disclosure is the disclosure is for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment), and (2) the PHI pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your medical 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 known at the time of registration or to the clinician. You may be asked to make your request in writing to be filed in the record. You must specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate reasonable requests to communicate by alternative means or alternative locations.

Right to be Notified of a Breach: You have the right to be notified in the event that we (or a business associate) discover a breach of unsecured PHI.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. Please contact the Privacy Officer to request a paper copy. You may also obtain a copy of this Notice on our web site at www.thefamilyconservancy.org.

For More Information or to Report a Problem:
If you have questions or would like additional information, you may contact our Privacy Officer. Our Privacy Officer may be reached:
By phone: 913-742-4214
By fax: 913-321-8922
By e-mail: privacyofc@tfckc.org
In person or by mail:
The Family Conservancy
434 Minnesota Ave
Kansas City, KS 66101
If you would like to report a problem or file a complaint regarding the use or disclosure of your PHI, or your rights regarding your PHI, you may contact our Privacy Officer. You also may file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you file a complaint with the Office for Civil Rights or with us.