Fellowship House
South Miami, Florida

NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICE 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 Monica Bosch-Batule, Privacy Officer at 305-670-1994.

WHO WILL FOLLOW THIS NOTICE
This notice describes Fellowship House’s practices and that of:

1. Any Fellowship House direct service staff that provide services to you and document such services.
2. Any health care professional involved in your care.

OUR PLEDGE REGARDING MEDICAL INFORMATION
Fellowship House understands that medical information about you is personal. Fellowship House is committed to protect the privacy of such information. Fellowship House creates a record of the care and services it provides for you while in Fellowship House program. Fellowship House needs this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your services received while at Fellowship House.

This notice will tell you about the ways in which Fellowship House may use or disclose medical information about you. This notice will also describe your rights and certain obligations Fellowship House has regarding the use and disclosure of medical information.

Fellowship House is required by law to:

• Make sure that medical information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you, and
• Follow the terms of the notice that is currently in effect.

HOW FELLOWSHIP HOUSE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that Fellowship House may use or disclose medical information. For each category of uses or disclosures we will explain what we mean. Not every use or disclosure in a category will be listed. However, all of the ways Fellowship House is permitted to use and disclose information will fall within one of the categories.

For Treatment. Fellowship House may use medical information about you to provide you with services. Fellowship House may disclose medical information about you to direct service staff that provide you with Fellowship House services or to psychiatrists or other doctors involved in your care/services.

For Payment. Fellowship House may use or disclose medical information about you so the services provided to you at Fellowship House may be billed or payment received from you insurance carrier/Medicaid/Medicare.

For Health Care Operations. Fellowship House may use and disclose medical/psychological information about you for Fellowship House operations. These uses and disclosures are necessary to operate Fellowship House services and making sure that all of our members receive quality care/services.

Appointment Reminders. We may use or disclose medical information to contact you for a reminder about an appointment with a Fellowship House staff or any doctors appointment made by one of your treatment team members.

Individuals Involved in Your Care or Payment for your services. Fellowship House may release information about you to a family member or any other individual who is involved in your medical care. Fellowship House may also give information to someone who helps pay for your Fellowship House services. In addition, Fellowship House may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition or location.

As Required by Law. Fellowship House will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. Fellowship House may use or disclose medical information about you when necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person. Such disclosure would only be to someone able to prevent the threat.

SPECIAL SITUATIONS
Organ and Tissue Donations. If you are an organ donor, Fellowship House may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank necessary to facilitate organ and tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, Fellowship House may release medical information about you as required by military command authorities.

Worker’s Compensation. Fellowship House may release medical information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries.

Public Health Risks. Fellowship House may disclose medical information about you for public health activities. These generally include the following:

• To prevent or control disease, injury or disability
• To report births or 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 Fellowship House believes a member has been the victim of abuse, neglect or domestic violence. Fellowship House will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. Fellowship House may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include 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 a dispute, Fellowship House may disclose medical information about you in response to a court or administrative order. Fellowship House may disclose medical information about you in response to a subpoena, discover request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. Fellowship House may disclose medical information if asked to do so by law enforcement officials:

• 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, Fellowship House is unable to obtain the person’s agreement
• About a death Fellowship House believes may be the result of criminal conduct
• About criminal conduct on Fellowship House premises
• 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

Coroners, Medical Examiners and Funeral Home Directors. Fellowship House may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Fellowship House may also release medical information about members of Fellowship House to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. Fellowship House may disclose medical information about you to authorize federal officials for intelligence, conterintelligence and other national security activities authorized by law.

Inmates. If you are an inmate of a correctional institution or under custody of a law enforcement official, Fellowship House may disclose medical information about you to the correctional institution or the law enforcement official. This would be necessary for the institution to provide you with health care, to protect your health and safety and the health and safety of others or for the safety and security of the member of Fellowship House

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes (this is up to the discretion of your primary staff person and the privacy officer).

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the privacy officer.

Fellowship House may deny your request in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. At such time, the Clinical Utilization Review Manager, will review your request and the denial. The Clinical Utilization Review Manager will not be the same person who originally denied your request. Fellowship House will abide by the outcome of the review.

Right to Amend. If you feel the medical information that Fellowship House has about you is incorrect or incomplete, you may ask Fellowship House to amend the information. You have the right to request an amendment for as long as the information is kept at Fellowship House.

To request an amendment, your request must be in writing and submitted to the privacy officer. In addition, you must provide a reason that supports your request.

Fellowship House 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, Fellowship House may deny your request if you ask us to amend information that:

• Was not created by Fellowship House
• Is not part of the information kept by Fellowship House
• Is not part of the information you would be permitted to inspect and copy
• Your clinical records is accurate and complete, as per your treatment team

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of the disclosures Fellowship House made of medical information about you.

To request this list of accounting, you must submit your request in writing to the privacy officer. Your request must state a time period, which may not be longer than six years and may include dates before March 1, 2003. Your request should indicate in what form you want the list (orally or in writing).

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information Fellowship House uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Fellowship House discloses about you to someone who is involved in your care or payment for your services, like a family member.

WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST. If Fellowship House agrees, it will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, you must make your request in writing to the privacy officer. In your request, you must tell us what information you want to limit, whether you want Fellowship House to limit our use, disclosure or both and to whom you want the limits to apply.

Right to Request Confidential Communications. You have the right to request that Fellowship House communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Fellowship House staff only contact you at home or not to call at home to remind you about certain appointments.

To request confidential communications, you must make your request in writing to the privacy officer. Fellowship House will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a copy of this notice. You may ask the privacy officer to give you a copy of this notice at any time. To obtain a copy of this notice, you must make your request in writing to the privacy officer.

CHANGES TO THIS NOTICE
Fellowship House reserves the right to change or revise this notice. Fellowship House reserves 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. Fellowship House will post a copy of the current notice on Fellowship House premises. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time the notice is revised we will offer you a copy of the notice and request a signed acknowledgment.


COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the privacy officer or the Secretary of the Department of Health and Human Services.

PRIVACY OFFICER – Andrea McFann
                                       5711 SOUTH DIXIE HIGHWAY
                                       SOUTH MIAMI, FL 33143
                                       (305) 670-1994 ext 1251


SECRETARY OF HEALTH AND HUMAN SERVICES

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019


OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to Fellowship House will be made only with your written permission. If you provide Fellowship House permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, Fellowship House will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that Fellowship House is unable to take back any disclosure it has been already made with your permission, and that Fellowship House is required to keep documentation of the services provided to you while at Fellowship House.