Domestic Violence Intervention Services, Inc.
Notice of Privacy Practices
This notice describes how Personal Health and 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: our Privacy Contact/Official:
Performance and Continuous Quality Improvement Coordinator or Director of Human Resources
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with the most current Notice of Privacy Practices. You may also access the notice by visiting our website at www.dvis.org, by calling our main office and requesting that a current copy be sent to you in the mail or by asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by your counselor or our office staff to sign a consent form related to usage of your protected health information. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, your counselor will use or disclose your protected health information as described in this Section 1. Your protected health information may be used and disclosed by your counselor, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing mental health and other health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of Domestic Violence Intervention Services, Inc. (DVIS).
Following are examples of the types of uses and disclosures of your protected health care information that Domestic Violence Intervention Services is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our offices once you have provided consent.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary and if appropriate pursuant to an evaluation by a DVIS counselor, to an agency that was currently providing mental health treatment or substance abuse treatment to you. We will also disclose protected health information to other mental health care or health care providers, to courts or to others who may be treating you or whom you have authorized to obtain your protected health care information when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a mental health or substance abuse provider to whom you have been referred by a DVIS counselor to ensure that the mental health or substance abuse provider has the necessary information to evaluate, diagnose or treat you or to a court or attorney whom you have given permission for your protected health care information to be released to.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval to cover the costs of your counseling sessions at DVIS may require that your relevant protected health information be disclosed to the health plan to obtain approval for the counseling sessions.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of DVIS. These activities include, but are not limited to, quality assessment activities, employee review activities, training of interns and staff, licensing, marketing and fundraising activities, legal activities, administrative activities and conducting or arranging for other business activities where not limited by relevant state or federal law.
For example, we may disclose your protected health information to an intern that sees clients at our office or who is conducting research in conjunction with DVIS. In addition, we may use a sign-in sheet or sheets at the registration desk where you will be asked to sign your name and indicate various items of information concerning yourself. We may also call you by name in the waiting room when your counselor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment or payment requirements.
We will share your protected health information with third party “business associates” that may perform various activities (e.g., billing, transcription services) for DVIS. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other mental health/health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about DVIS and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from your counselor or other DVIS treatment or services provider, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materials not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your counselor, DVIS service provider or DVIS has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your counselor or DVIS service provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your mental health/health care and not limited by relevant state or federal law will be disclosed.
Others Involved in Your Healthcare: DVIS will not release your personal health information to others who are not employees of DVIS unless you have signed a release allowing us to do so and your counselor or service provider feels it is appropriate to do so, we are required per state or federal law by a court to do so, or as described above or below.
Communication Barriers: We may use and disclose your protected health information if your counselor or DVIS service provider or another DVIS counselor or DVIS service provider attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the counselor or DVIS service provider determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health or DVIS program oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, DVIS programs, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. DVIS will only do so where required by law to do so. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure IS expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. DVIS may disclose protected health information in the course of any judicial or administrative proceeding, in response to a suit or proceeding against DVIS or DVIS interests.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise as required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Research: We may disclose your protected health information to researchers when their research has been approved by a DVIS review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual and such disclosure is required by law.
Military Activity and National Security: When the appropriate conditions apply, we may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your counselor created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains health and/or billing records and any other records that your counselor or DVIS service provider and DVIS uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your health record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your counselor, DVIS service provider or DVIS is not required to agree to a restriction that you may request. If your counselor, DVIS service provider or DVIS believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your counselor, DVIS service provider or DVIS does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment or required by law. With this in mind, please discuss any restriction you wish to request with your counselor, DVIS service provider or the DVIS privacy contact. You may request a restriction by contacting our Privacy Official.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
You may have the right to request to have your counselor amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your health record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you previously or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to 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 contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact one of our Privacy Officers, at (918-585-3163) for further information about the complaint process.
This notice was published and becomes effective on April 14, 2003.