Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Constellation Health Services is required by law to maintain the privacy of your health information and to provide you this detailed Notice of our legal duties and privacy practices relating to your health information. Constellation shall abide by the terms of the Notice that are currently in effect. However, Constellation reserves the right to change the terms of this Notice and to make the new provisions effective for all personal health information received and maintained by Constellation now and in the future. We will provide you with a copy of the revised Notice upon request. In addition, a copy of the effective Notice will be posted at all times in the office with a date notifying you of the most recent update.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

As a patient of Constellation, information about you must be used and disclosed to other parties for purposes of treatment, payment, and health care operations. These uses and disclosures do not require your consent:

1. For Treatment. We will use and disclose your health information in providing you with treatment and services and coordinating your care and may disclose information to other providers involved in your care. Your health information may be used by doctors involved in your care and by nurses and home health aides as well as by therapists, pharmacists, suppliers of medical equipment, assisted living staff, or other persons involved in your care. For example, we will contact your physician to discuss your plan of care.
2. For Payment. We may use and disclose your health information for billing and payment purposes. We may disclose your health information to your representative, or to an insurance or managed care company, Medicare, Medicaid or another third-party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request approval for services that will be provided to you.
3. For Health Care Operations. We may use or disclose your health information as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor our quality of care. We may disclose your health information to past, present or future medical providers for the same purpose, for health care fraud and abuse detection or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services.

SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following lists various ways in which we may use or disclose your health information for which you are consenting or as required by law or as allowed by HIPAA.

1. Individuals Involved in Your Care or Payment of Your Care. Unless you object, we may disclose health information about you to a family member, close personal friend or other person you identify, including clergy, who is involved in your care.
2. Emergencies. We may use or disclose your health information as necessary in emergency treatment situations, or in the event of the possibility of service interruption if you are considered at risk by Constellation Health Services.
3. As Required By Law. We may use or disclose your health information when required by law to do so.
4. Business Associate. We may disclose your personal health information to a contractor or business associate who needs the information to perform services for Constellation. To protect your health information, we have our business associates sign written contracts that require them to keep your information confidential. For example, our computer consultant may have access to certain personal health information, but is required by law and our contract with them to keep the information confidential and not use it.
5. Public Health Activities. We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting to the Federal Food and Drug Administration issues concerning problems with products or product recalls, or reporting births and deaths.
6. Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use or disclose your health information to notify a government authority, if authorized by law, or if you agree to the report.
7. Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system.
8. To Avert a Serious Threat to Health or Safety. We may use or disclose health information to prevent a serious threat to your health or safety or the health or safety of others limiting disclosures to someone able to help lessen or prevent the threatened harm.
9. Judicial and Administrative Proceedings. We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process.
10. Law Enforcement. We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
11. Research. We may use or disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.
12. Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.
13. Disaster Relief. We may disclose health information about you to a disaster relief organization.
14. Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities or for the purpose of determining your eligibility for benefits by the Department of Veterans Affairs. We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.
15. Benefit Programs. We may use or disclose your health information to comply with laws and obligations relating to workers’ compensation or other similar State or Federal benefit programs.
16. Inmates/Law Enforcement Custody. If you are under the custody of a law enforcement official or a correctional institution, we may disclose your health information to the institution or official for certain purposes including the health and safety of you and others.
17. Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your health information to inform you about treatment alternatives and healthrelated benefits and services that may be of interest to you and that are offered by Constellation or its affiliates and its contracted partners.
18. Appointment Reminders. We may use or disclose health information to remind you about appointments.

II. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Most uses and disclosures of psychotherapy notes and of personal health information for marketing purposes and the sale of personal health information require an individual’s authorization. Constellation WILL NOT BE SELLING YOUR PERSONAL HEALTH INFORMATION AT ANY TIME. Uses and disclosures not described in this Notice will be made ONLY with your Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

III. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to Constellation by you. At your request, Constellation will supply you with the appropriate form to complete, if you wish.

1. Request Restrictions. You have the right to request restrictions on our use or disclosure of your health information for treatment, payment or health care operations. You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.
   
   We are not required to agree to your requested restriction (except if you restrict disclosures to family members or friends other than a conservator or listed health care agent). If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment or in accordance with applicable law. However, you have the right to restrict certain disclosures of personal health information to a health insurance payor where the disclosure is for payment or health care operations and pertains to a health care item or service for which you (or any person other than the health insurance payor) have paid for the treatment in full.
2. Access to Personal Health Information. You have the right to request copies of your personal health information in any form you choose, provided that the personal health information is readily producible in that format. You have the right to request your personal health information electronically or have it directly transmitted to a third party specified by you per our capabilities. Your request must be made in writing. In most cases we may charge a reasonable, cost-based fee for preparing the copy, which will not exceed our labor costs in responding to your request and postage, if applicable.
   
   We may deny your request to inspect or receive copies in certain circumstances. If you are denied access to health information, in some cases you have a right to request review of the denial. This review would be performed by a licensed health care professional designated by Constellation who did not participate in the decision to deny.
3. Request Amendment. You have the right to request amendment of your health information maintained by Constellation for as long as the information is kept by or for Constellation. Your request must be made in writing and must state the reason for the requested amendment.
   
   We may deny your request for amendment if the information (a) was not created by Constellation, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for Constellation (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by Constellation.
   
   If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
4. Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your health information. This is a listing of disclosures made by Constellation or by others on our behalf. This includes disclosures made for treatment, payment and health care operations if the disclosures are made through an electronic health record.
   
   To request an accounting of disclosures, you must submit a request in writing, stating a time period that is within six years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.
5. Request a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. In addition, you may obtain a copy of this Notice on our website, www.constellationhs.com.
6. Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.
7. Notification of Breach of Security. You have the right to be notified of an unauthorized disclosure of your unsecured personal health information and we will notify you of such a breach in accordance with our obligations under the law.

IV. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION

For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. Except as provided below and as specifically permitted or required under state or federal law, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization.

• Psychiatric information. If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed. Certain limited information may be disclosed for payment purposes.
• HIV related information. HIV-related information may be disclosed for purposes of treatment or payment.
• Substance abuse treatment. If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies.

V. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights or wish to make any requests, opt-out of receiving certain communications or object to a disclosure, please contact HIPPA Compliance Officer at Constellation Health Services at 1-866-375-9366.

If you believe that your privacy rights have been violated, you may file a complaint in writing with Constellation Health Services or with the Office for Civil Rights in the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201. Complaint may also be made by phone to 1-877-696-6775. We will not retaliate against you if you file a complaint.