NOTICE OF PRIVACY PRACTICES

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.

If you have any questions about this notice, please contact Family Service Association.

Family Service Association (FSA) provides many types of services, such as mental health and social services. In order to provide these services to you, we must collect personal health information from you. We know that this information is private, and that we must protect this information according to Federal and State law. This personal health information is called "protected health information (PHI)."

The following information tells you how FSA may use or disclose this information about you. For each situation, we will try to give an example. Not every use or disclosure in a category will be listed. All of the ways we are permitted to use and disclose your PHI will fall within one of these categories. We may use or disclose this information orally, in writing or electronically.

For Treatment: We may use or disclose your information with other health care providers at FSA who are involved with your treatment. For example, your therapist will present your case for review by our staff psychiatrist and for treatment planning. Your PHI will NOT be disclosed to health care providers outside of FSA without your written consent.

For Payment: We may use or disclose your PHI to receive payment for the health care services you receive. For example, health insurance companies frequently ask for health information to authorize payment for services provided to you.

For Health Care Operations: FSA may use or disclose your PHI for internal management of our programs and activities. These uses and disclosures will help us to assess the quality of service you are receiving.

For example: your file may be reviewed by FSA personnel to ensure that all information required for our accreditation process is included in the file, accurately and completely. Business Associates: We sometimes contract with outside organizations, called business associates, to provide certain operational tasks for us. Examples of business associates are agencies that provide technical support for our client information programs, financial auditors, accrediting bodies, etc. They are provided with your medical information to perform the tasks that we ask of them. However, in order to protect your health information, we do require that they safeguard your information, just as we do. They are NOT allowed to release your PHI.

Appointment Reminders: We may disclose your health information in order to remind you of your scheduled appointments. For example, a mailed notice or a telephone call, to remind you of an appointment.

Treatment Alternatives: We may use and disclose your health information in order to let you know about alternatives for your treatment plan. For example, if we were to refer you to inpatient therapy, we would use and disclose your medical information to provide a referral. Your PHI would only be released with your written permission.

Health-Related Benefits and Services: We may use and disclose your PHI to tell you about health-related benefits or services. For example, if we were to start up a new support group that could benefit you, we would let you know about it.

Individuals Involved in Your Care or Payment for Your Care: With your written permission, we may disclose medical information to a member of your family, a relative, a close friend or any other person you identify.

THE FOLLOWING USES AND DISCLOSURES ARE REQUIRED OR PERMITTED BY LAW

Serious Threat to Health or Safety: We may use or disclose medical information about you if necessary in order to prevent a serious threat to your health and safety or the health and safety of another person or the public. This information would only be disclosed to prevent the threat.

Military and Veterans: We may release medical information about you, as required by military command authorities, if you are a member of the armed forces. However, we would make every reasonable effort to secure your written permission or objection prior to any such release.

Workers' Compensation: With your written permission, your PHI may be disclosed to workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks and Public Safety Issues: PHI may be disclosed about you for public health activities to ensure your safety. These activities could include the following:

-prevent or control disease, injury or disability
-to report actual or suspected elder abuse or neglect
-to report reactions to medication or treatment.
This information would only be disclosed when required or authorized by law.

Health Oversight Activities: FSA may disclose your PHI 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.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. However, we would make every reasonable effort to secure your written permission for objection prior to any such release.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official:

-In response to a court order, subpoena, warrant, summons or similar process;
-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 any FSA 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.

Research: Your PHI may be used in developing reports and research or studies for the agency. These reports do not identify specific people. Disclosures to Family, Friends and Others: With your written permission, we may disclose medical information to a member of your family, a relative, a close

Other Uses of Medical Information: Other uses and disclosures of your PHI not covered in this notice or law will be made only with your written permission. If you provide us permission to use and disclose your medical information, you may revoke permission, in writing, at any time. We cannot, however, take back any disclosures of the information we have already made with your permission. We are required by law to retain our records of the services that we provide to you.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

Right to Inspect and Copy: You have the right to request to inspect your file to make decisions about your treatment plan. This would include medical and billing records. However, this does NOT include psychotherapy notes.

You may also request copies of your file for yourself or to be sent to another facility. This request MUST be in writing. FSA may take up to 3 business days to respond to your request. If you request a copy of your information, we may charge a fee for copying, mailing and paper costs associated with this request. We may however, refuse your request to inspect or copy your file in some limited circumstances. If you receive a denial of your request, you may request a review of the denial by a licensed professional designated by FSA to act as the reviewing official. This official must not have participated in the original denial. FSA will then be obligated to abide by the decision made by the reviewing official. Right to Request an Amendment to Your Treatment Plan: If you have followed the appropriate plan to request a copy of your medical information and the request has been approved, you may also request an amendment to your file if you feel there is a mistake.

In order for you to make an amendment to the file or your treatment plan, you must first request the amendment in writing to the Family Service Association Privacy Officer. In addition to this request, we ask that you also provide reasoning for the amendment.

This request may be approved or denied if it is not in writing or does not include a valid reason for the change. If you request the amendment for any of the following reasons, your request may be denied:

-if the information that you wish to change has not been created by an FSA employee or the person who created the information is no longer an employee or available for review of your file. -if the information is in a part of the file that your therapist or the Privacy Officer deems is not permissible for you to inspect.
-if the information already in the treatment plan or file is accurate and complete.

Right to Receive a List of Disclosures: You have a right to receive documentation of any uses or disclosures of your PHI. This list will be comprised of any uses or discloses made of your treatment plan or file after April 14, 2003. The request for this list must be received in writing. The request must state a time period no longer than six years. We are not required to include the times that the information is released for treatment, payment or normal operating procedures. It also may not include the disclosures to you or your family members or information we disclosed with your authorization.

Right to Request Restrictions of Disclosure: You have the right to limit the uses and disclosures of your information. If you wish to terminate the restrictions at any time, this request must be submitted in writing.

The request to limit the uses and disclosures must be submitted in writing and must include the limits you wish to have on the release of your information. You must also include if you want to limit the use or disclosure or both, and it must also say to whom the limits apply.

We have the right to disagree with your request. If we agree with your request for restrictions, we do have the right to not comply with your request if emergency treatment is required. This request will also not affect disclosures that have already been made.

Right to Request Confidential Communications: It is your right to request that all communication between you and FSA is conducted in a certain way or location. For example, you may request that we only contact you by mail. This request must be made in writing to the Family Service Association Privacy Officer. We will accommodate all reasonable requests. You must specify how and where you wish to be contacted.

Right to a Paper Copy of this Policy: You have the right to request a paper copy of this policy at any time.

Contact Information to Review, Correct or Limit your Protected Health Information (PHI) You may contact the Privacy Officer at Family Service Association at the following address:
Family Service Association of Howard County, Inc.
Attention: Privacy Officer
618 S. Main Street
Kokomo, IN 46901
765-457-9313
765-868-4122 (Fax)

You may contact the Privacy Officer to:
-Request a copy of or look at your records
-Request a limit of uses and/or disclosures
-Request a cancellation of previous requests
-Request a change to your record
-Request of list of disclosures of your records

FSA may deny a request to look at, copy or change your records as stated previously. If we deny your request, a letter will be sent to you to explain why the request has been denied and how you can ask for a review of the denial. You will also receive information on how to file a complaint with FSA or with the U.S. Department of Health and Human Services, Office of Civil Rights.

If you believe your privacy rights have been violated, you may file a complaint in writing with the FSA Privacy Officer or the Secretary of the Department of Health and Human Services. All complaints must be made in writing.

You will NOT be penalized for filing a complaint.

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 medical 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 the Waiting Room at the FSA office. The notice will contain the effective date of the changes or revisions. If you request a copy of the revisions or changes, the copy will be made available to you if you request a copy.