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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 carefully.
We will ask for your signature to indicate that you have received a copy of this document at your first visit to the health center after 4/14/2003
For more information, questions, or an Expanded Version of our Notice of Privacy Practice ask for: Ivette Becerra-Ortiz, NP, MPH, Privacy Officer
Who We Are:
This Notice describes the privacy practices of Fair Haven Community Health Center (“we” or “Health Center”) and the privacy practices of:
- All of our clinicians and other health care professionals authorized to enter information about you into your medical chart.
- All of our departments, including our medical records and billing departments.
- All of our health center sites including the Medical Center at Bella Vista. Our school based health centers will be covered under the Notice of Privacy Practices of the New Haven Board of Education.
- All of our employees, staff, volunteers and other personnel who work for us or on our behalf.
Our Pledge:
We understand that health information about you and the health care you receive is personal. We are committed to protecting your personal health information. When you receive treatment and other health care services from us, we create a record of the services that you received. We need this record to provide you with quality care and to comply with legal requirements. This notice applies to all of our records about your care, whether made by our health care professionals or others working in this office, and tells you about the ways in which we may use and disclose your Personal Health Information (PHI). This notice also describes your rights with respect to the health information that we keep about you and the obligations that we have when we use and disclose your health information.
We are required by law to:
- Make sure that health information that identifies you is kept private.
- Give you this notice of our legal duties and privacy practices with respect to your personal health information.
- Follow the terms of the notice that is currently in effect for all of your personal health information.
How We May Use and Disclose Your Health Information:
Federal law allows us to use and disclose your personal health information for:
- For Treatment provided to you
- For Payment for services provided to you
- For Health Care Operations of the health center
However, since Connecticut law continues to require that we obtain your consent for disclosure of personal health information for payment purposes (e.g., your insurer will require certain information to support our claim for payment), coordination of care with other providers (e.g., discharge planning and referrals), and the disclosure of certain sensitive information protected under Connecticut law, we will request your consent for disclosure of personal health information upon registration.
Unless you object or specifically request to restrict use, some of the other ways in which the Health Center will use your personal health information are:
- Appointment Reminders
- Health-Related Services and Treatment Alternatives (i.e. referrals)
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Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to your family member(s), legally authorized representative(s), and any other person identified by you, which is directly relevant to such person’s involvement in your care or payment for your care, and to notify or assist in the notification of a family member, a personal representative, or any other person responsible for you. Such notification may include your location, general condition, or death, but will not include confidential HIV-related, drug and alcohol or mental health information. If you are able, we will provide you with the opportunity to consent or object to such disclosure. If you are unable to object due to your incapacity or an emergency circumstance, the Health Center, based upon its professional judgment, will make such disclosure if it determines that it is in your best interest to do so. Such disclosure of personal health information will be limited to information that is directly relevant to the recipient’s involvement in your health care.
We may make disclosures of your personal health information to a public or private entity charged by law or its charter to assist in disaster relief efforts for the purposes of coordinating the disclosures described in the above paragraph.
- Research
- Organ and Tissue Donation (If you are an organ donor)
- As Required By Law
- To Avert a Serious Threat to Health or Safety
- Military and Veterans
- Workers’ Compensation
- Public Health Activities: We may disclose health information about you for public health activities. 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.
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 patient 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.
- Health Oversight Activities: We may disclose health information about you to a health oversight agency for activities authorized by law
- Food and Drug Administration.
- Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order.
- Law Enforcement
- Coroners, Health Examiners and Funeral Directors
- National Security and Intelligence Activities
- Protective Services for the President and Others
- Inmates
All other uses or disclosures will only be made with your specific written authorization, which may be revoked, except to the extent it has already been relied upon.
Special rules apply for Psychiatric, Drug and Alcohol and HIV-related protected information: (see expanded version of Notice of Privacy Practices)
Your Rights:
You have certain rights with respect to your personal health information. This section of our notice describes your rights. If you have a question about how to proceed with these rights, contact our Privacy Officer identified above.
- Right to Inspect and Copy your Personal Health Information
- Right to Amend your Personal Health Information
- Right to Receive an Accounting of disclosures
- Right to Request Restrictions
- Right to Receive Confidential Communications
- Right to a Paper Copy of this Notice
- Right to a notification of changes to this Notice
Complaints:
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing a written description of your complaint, by telling your complaint in person to a Patient Advocate or by telling your complaint over the phone to:
Ivette Becerra-Ortiz, NP, MPH
Privacy Officer
Fair Haven Community Health Center
374 Grand Avenue
New Haven, CT 06513
(203) 777-7411
Please describe what happened and give us the dates and names of anyone involved. Please also let us know how to contact you so that we can respond to your complaint.
You may file a complaint with the Secretary of the Department of Health and Human Services by contacting:
Office of Civil Rights
U.S. Department of Health and Human Services - Government Center
J.F. Kennedy Federal Building, Room 1875
Boston, MA 02203
(617) 565-1340 Fax (617) 565-3809 TDD (617) 565-1343.
You will not be penalized for filing a complaint.
Other Uses and Disclosures of Your Protected Health Information:
Other uses and disclosures of personal health information not covered by this notice or applicable law will be made only with your written authorization. If you give us your written authorization to use or disclose your personal health information, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your personal health information for the reasons covered by your written authorization. You understand that we are unable to take back any uses and disclosures that we have already made with your authorization, and that we are required to retain our records of the care that we have provided to you.
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