SHORT VERSION* OF BRIDGES NOTICE OF PRIVACY PRACTICES AND CONSENT FORM

 

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

 

Bridges is required by law to maintain the privacy of your health information and to provide you with this detailed Notice of our legal duties and privacy practices with respect to your health information. .Bridges shall abide by the terms of the Notice that are currently in effect.  However, Bridges   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 Bridges 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 wait areas with a date notifying you of most recent update.

 

I.  USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

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

 

• 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 our staff as well as to any other health care provider involved in your care, either within Bridges or an outside healthcare provider.  For example, we disclose information about your health condition to a referring physician, a pharmacist who needs the information to dispense a prescription or a laboratory that requires it to perform testing. 
• 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.
• For Health Care Operations - We may use and 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 same purpose, for health care fraud and abuse detection or compliance activities.  For example, health information of many clients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services.
   

II.   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.

Individuals Involved in Your Care or Payment of Your Care, Emergencies, As Required By Law, Business Associate, Public Health Activities, Reporting Victims of Abuse, Neglect or Domestic Violence, Health Oversight Activities, To Avert a Serious Threat to Health or Safety, Judicial and Administrative Proceedings, Law Enforcement, Research, Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations, Disaster Relief, Military, Veterans and other Specific Government Functions, Workers’ Compensation and other Benefit Programs, Inmates/Law Enforcement Custody,  and Appointment Reminders.

• Fundraising Activities.  We may use certain limited information to contact you in an effort to raise funds for Bridges and its operations.  However, you may opt-out from receiving such communications.
• Treatment Alternatives and Health-Related Benefits and Services. We may use or disclosed health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you and that are offered by Bridges or its affiliates and its contracted partners, including Communicare and Genoa Pharmacy.
• Appointment Reminders - We may use and disclose health information to remind you of appointments within our agency.
   

III.   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. Bridges 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.

     

IV. 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 Bridges by you.  At your request, Bridges will supply you with the appropriate form to complete, if you wish.

 

Request Restrictions - You have the right to request certain restrictions on our use or disclosure of your health information for treatment, payment and 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.

Access to Personal Health Information - You have the right to request copies of your personal health information in any form you choose, provided that your 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 the health information, in some cases you have the right to request review of the denial.  This review would be performed by a licensed health care professional designated by Bridges who did not participate in the decision to deny.

Request Amendment - You have the right to request an amendment to your health information maintained by Bridges for as long as the information is kept by or for Bridges.  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 Bridges, 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 Bridges; (c) is not part of the information to which you have the right of access; or (d) is already accurate and complete, as determined by Bridges. 

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 Bridges or by other 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 twelve-month period will be free; for further requests, we may charge you our costs.

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 web site, www.bridgesct.org

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. 

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

 

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 Jaya Daptardar, Privacy Officer at 203-878-6365 x 322.

If you believe your rights have been violated, you may file a complaint in writing with Bridges 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.

 

 I acknowledge that I have read or had this Notice explained to me.  I understand this Notice and have had the opportunity to ask questions regarding any matters of concern and signing it voluntarily.

(*excludes explanation of listed disclosures and Connecticut’s confidentiality laws)