(Health Insurance Portability and Accountability Act)
Notice of PrivacyPractices
Federal Law requires that this agency maintain the privacy of your protected health information (PHI). We are not allowed to use or disclose your PHI to another person or agency unless we receive written consent or authorization signed by you, or as otherwise permitted by law.
Protected Health Information includes, but is not limited to, the following: Information, verbal, in writing or other recorded format, that is
- Created by a health care provider, and
- Relates to past, present or future medical or mental health conditions or
- Relates to the provision of health care services or
- Relates to the past, present or future payment of health care services.
This agency has legal responsibilities with respect to your protected health information, including the responsibility to inform you of how and when Affinity Healthcare Group – Cherry Hill might use and disclosure your protected health information. We must also inform you of your rights and our duties related to your protected health information.
Affinity Healthcare Group – Cherry Hill Duties:
- Confidential Facility
- This agency is required to safeguard your protected health information to the best of its abilities.
- This agency is required to develop and implement policies and procedures to assure that your protected health information remains confidential
- This agency is required to train its staff in procedures to assure that your protected health information is kept strictly confidential.
- This agency is required to designate a staff person who is responsible for assuring the protections of health care information and for reviewing our agency’s policies and procedures.
- This agency has the responsibility to abide by all of the information contained in this consent form. If this agency changes any of the information in this consent form, we must notify you of any changes.
- Use And Disclosure Of Protected Health Information
There are three types of disclosures related to your protected health information: those required by law, those for which we need your written consent, and those that do not require your written consent. This agency must maintain a written record of all disclosures of your protected health information.
a. Required Disclosures
In some cases, this agency may be required by law or other federal or state regulation to disclose your protected health information. This could include any of the following circumstances:
- Audits by state and federal regulatory and enforcement agencies,
- Investigations of complaints by state and federal regulatory and enforcement agencies, and/or
- Reporting of communicable diseases as defined by state and federal health statutes
b. Disclosures Requiring Your Consent
For all other situations, Federal law prohibits Affinity Healthcare Group – Cherry Hill from disclosing your protected health information without your proper written consent. If this agency has a need to make any other disclosures of your personal health information, we must obtain your written consent to do so. These may include written consent for any of the following activities:
- For purposes of treatment, payment and health care operations,
- To communicate with agency staff and business associates in the coordination of your treatment and health-related services,
- To communicate with other treatment agencies and service providers regarding your past, present or future treatment needs and experiences,
- To communicate with your family and significant others, and/or
- To communicate with criminal justice system representatives regarding your case (if applicable).
c. Disclosures that do not require your consent
While we may not necessarily make all of the uses and disclosures described below, federal law permits use or disclosure or protected health information without your written consent or authorization under the following circumstances:
- Your protected health information is required by a court order in a specific legal case,
- Your protected health information is necessary to help medical personnel in a medical emergency related to you,
- Your protected health information is used for the purposes of research, audit, or program evaluation,
- If this agency reasonably believes that you may try to harm yourself or someone else,
- If you are suspected of child abuse or neglect, and/or
- If you commit, or threaten to commit, a specific crime on premises or against agency staff.
- Record of Disclosures
Affinity Healthcare Group – Cherry Hill will maintain a written record of all disclosures made regarding your personal health information. This record will include the name of the person or agency to which the information was disclosed, the type of information disclosed, and the date on which the disclosure was made.
- Access to Records
Affinity Healthcare Group – Cherry Hill is required, with certain exceptions, to provide you with access to inspect and obtain a copy of your protected health information that we maintain in our record system.
- Need for Authorization
This agency will not make any uses or disclosures other than those mentioned above without your written authorization, in accordance with federal law.
- Inform Patient of Breach
If this agency reasonably believes that there has been a breach of your confidentiality, we have an obligation to inform you of the breach, including the information that was shared, to whom the information was shared, and our plan for corrective action.
- Informed Consent
Federal Law requires that you be informed of your rights in regard to your protected health information and that you authorize the use and disclosure of your protected health information at this agency.
You have the right to revoke your consent to disclose your protected health information. You may revoke you authorization either verbally or in writing, except under two conditions. Your revocation will not be effective if
a. We took action relying on the written authorization before it was revoked, or
b. We obtained the authorization as a condition of a court order, probation or parole placement. In these cases, we are authorized to continue to communicate with the identified court officers up to and including your discharge from treatment.
3. Restricted Access
You have the right to request that restrictions be placed on certain uses and disclosures of your protected health information as permitted by law. To assure that agency staff fully understands your wishes with regard to your protected health information, you will be asked to consent to specific health information on each consent form.
- Right to Inspect Records
You have the right to inspect and copy your protected health information, except for any psychotherapy notes, information relating to civil, criminal, or administrative proceedings, and certain information prohibited by law from disclosure. We are allowed by law to deny access in some circumstances. This agency has developed policies and procedures related to access of your record. If you desire to review a copy of your record, you must request access through your primary counselor.
- Right to Amend
You have the right to request that we amend your protected health information maintained in our records. We are permitted to deny your request if we did not create the information in the record. We will review any such request in accordance with federal law and respond to you in writing. Any such request should be in writing and addressed to the Executive Director of this agency. All requests for amendment should provide necessary details, including your name, address, dates of service and a reason supporting your request for the amendment.
- Right to an Accounting
You have the right to receive an accounting from us of disclosures of protected health information about you made for up to the six (6) years prior to your request for the accounting. This right does not apply to the following: disclosures made to carry out treatment, payment, or health care operations; disclosures made pursuant to an authorization in compliance with federal law; disclosures made for law enforcement purposes; disclosures authorized by law; or disclosures that occurred before April 14, 2003. Any request for an accounting should be sent to the Administrator of this agency.
- Right to Be Informed of Breach
You have the right to be informed of any breach of your confidential information within four (4) days of the time of the breach or the time when this agency became aware of the breach, including the information that was shared, to whom the information was shared and our plan for corrective action.
- Right to Complain/Grievance Procedure
If you believe your privacy rights have been violated, you have the right to complain. You can address your complaint, in writing, to any of the following:
Affinity Healthcare Group – Cherry Hill
1305 Kings Hwy North
Cherry Hill, NJ 08034
Complaints & Investigations
New Jersey Department of Human Services
Division of Addiction Services
P.O. Box 362
Trenton, NJ 08625
Secretary of the Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue
Washington, DC 20201.
Federal law prohibits retaliation against you for filing such a complaint.