This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Review it carefully.

St. John’s Community Services (SJCS) has a long history of concern and advocacy regarding your right to privacy.  This notice will tell you about your rights and our duties with respect to your health information.  This notice will tell you how we may use and disclose protected health information about you and how to complain if you believe we have violated your privacy rights.

In this notice “we” shall refer to St. John’s Community Services and members of its workforce.  Protected health information is any health information about you that identifies you such as your name, Social Security number Medicaid number etc.  In the header above, protected health information is referred to as “medical information.”  In the remainder of this notice, we simply call all protected health information, “health information.”

Your Rights

Right to Request Restrictions

You have the right to request from your Program Director, a restriction on the uses or disclosures of your health information.  You may do so at any time. If you request a restriction, you should tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your spouse).

We will take all requests seriously, and will give you a prompt response.  We are not, however, legally required to agree to any requested restrictions.  If we do agree, we will follow that restriction unless the information is needed to provide emergency treatment.  Even if we agree to a restriction, either you or we can later terminate the restriction.

Right to Confidential Communication

You have the right to request that we communicate health information about you to you in a certain way or correspond to you at a certain location. For example, you can ask that we only contact you by mail or at work.  If you want to request confidential communication, you must do so in writing to your Program Director. Your request must state how or where you can be contacted. We will accommodate all reasonable requests

Right to Inspect and Copy

With a few very limited exceptions, such as psychotherapy notes, you have the right to inspect and obtain a copy of your health information.

To see or copy your health information, you must submit your request in writing to your Program Director. Your request should state specifically what health information you want to see or copy.  If we agree to your request we will let you know when and how you can see and obtain copies of your health information. We may charge a fee for the copies and related expenses.

In limited situations, we may deny some or all of your request to see or receive copies of your heath information.  If this happens you will receive the decision in writing along with an explanation on how to appeal the decision.

Right to Request a Change

You have the right to ask us to change health information about you.

To request a change or amendment, you must submit your request in writing to your Program Director. Your request must state the change desired and provide a reason in support of that amendment.

We will respond in writing to your request.  If we approve the request we will make the change to your health information.  If we deny your request, we will tell you why and explain your right to file a written statement of disagreement and to complain about our decision.

Right to an Accounting of Disclosures

You have the right to receive an accounting of disclosures of your health information made by SJCS unless they were: a) disclosed to you, b) disclosed for the purpose of treatment, payment, health care operations, or c) authorized by you.

To request an accounting of disclosures, you must submit your request in writing to your Program Director. Your request must state a time period for the disclosures.  It may not be longer than six (6) years from the date we receive your request and my not include dates before April 14, 2003.

There is no charge for the first accounting we provide to you in any twelve (12) month period.  For additional accountings, we may charge you for the cost of providing the list.  If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.

Right to Copy of this Notice

You have the right to obtain a paper copy of our Notice of Privacy Practices.  You may obtain a paper copy even though you agreed to receive the notice electronically.  You may request a copy of our Notice of Privacy Practices at any time.

You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site, www.SJCS.org.

To obtain a paper copy of this notice, contact your Program Director or the Chief Evaluation and Planning Officer, St. John’s Community Services, 2201 Wisconsin Avenue NW, Suite C-150, Washington DC, 20007, 202- 237-6500.

How We May Use and Disclose Your Health Information

Your confidentiality is important to us. Upon receipt of the SJCS Consent for Use and Discloser form, we may use and disclose your health information in order to provide treatment, receive payment and conduct day to day health care operations.

Treatment

We may use health information about you to provide, coordinate or manage the services, supports, and health care you receive from us and other providers. We may disclose health information about you to doctors, nurses, qualified mental retardation professionals (QMRPs), psychologists, social workers, behavior specialists, direct support staff and other agency staff, volunteers and other persons who are involved in supporting you or providing care.  For example, staff may discuss your information to develop and carry out your individual service plan (ISP).  Staff may share information to coordinate needed services, such as medical tests, transportation to a doctor’s visit, physical therapy, etc.  Staff may need to disclose health information to entities outside of our organization to obtain new services for you.

Payment

We may use and disclose your health information. so we can be paid for the services we provide to you.  This can include billing a third party payor, such as Medicaid or other state agency (for example, the state’s Office of Mental Retardation), or your insurance company.  For example, we may need to provide the state Medicaid program information about the services we provide to you so we will be reimbursed for those services. We also may need to provide the state Medicaid program with information to verify your eligibility.

Health Care Operations

We may use and disclose health information about you for our own operations.  These are necessary activities for SJCS to operate and to maintain quality for our consumers.  For example, we may use health information about you to review the services we provide and the performance of our employees supporting you.  We may disclose health information about you to train our staff and volunteers.  We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program.

Individuals Involved in Your Care, Circle of Support or Payment

Unless you object, health information about you may be released to a friend, family member or other individual involved in your care.  We may also release information to someone who helps pay for your care.

Circumstances for Disclosures

As permitted or required by state law health information about you may be disclosed for the following reasons:

•    As required by law.

•    For certain public health activities, such as to a public health authority in order to control the spread of disease.

•    In response to judicial and administrative proceedings, such as in response to an order of the court or administrative tribunal.

•    For law enforcement purpose, such as in response to a warrant or subpoena.

•    To avert serious threat to Health and Safety of another person.

•    For children or incapacitated adults who are suspected victims of abuse, neglect or exploitation.

•    For specialized government functions, such as matters of national security or to government programs that provide certain public benefits.

•    To facilitate worker’s compensation processing and payment.

•    For certain health oversight activities authorized by law, such as licensure, audits, investigations or inspections.

•    To Coroners, Medical Examiners, and Funeral Directors in order for them to carry out their duties.

•    To facilitate organ, eye, or tissue donation and transplantation.

•    Unless you object, to a public or private entity authorized by law or charter to assist in disaster relief efforts.

How We Will Contact You

Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace.  At either location, we may leave messages for you on the answering machine or voice mail to:

•    Remind you about appointments.

•    Contact you about treatment and service alternatives

Fundraising

We may use and disclose health information about you to raise funds for SJCS.  We may disclose health information to a business associate of SJCS or a foundation related to SJCS so that business associate or foundation may contact you to raise money for the benefit of SJCS.  We will only release demographic information, such as your name and address, and the dates you received treatment or services from SJCS.  If you do not want SJCS or its foundation to contact you for fundraising, you must notify in writing the Marketing and Fundraising Manager, St. John’s Community Services, 2201 Wisconsin Avenue NW, Suite C-150, Washington DC, 20007, 202-237-6500.

Other Uses and Disclosures

Other uses and disclosures will be made only with your written authorization.  You may revoke such an authorization at any time by notifying your Program Director in writing of your desire to revoke it.  However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.

Our Responsibilities

We are required by law to maintain the privacy of health information about you and to provide you with notice of our legal duties and privacy practices with respect to health information.

We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

Right to Change Notice of Privacy Practices

We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.

Availability of Privacy Notice

A copy of our current Notice of Privacy Practices will be posted at SJCS’s physical sites.   A copy of the current notice also will be posted on our web site, www.SJCS.org.

You may obtain a copy of the current Notice of Privacy Practices by contacting your Program Director or direct support staff.

Complaints

You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with us, contact your Program Director or the Chief Evaluation and Planning Officer, St. John’s Community Services, 2201 Wisconsin Avenue NW, Suite C-150, Washington DC, 20007 in writing.

You will not be retaliated against for filing a complaint.

Questions and Information

If you have any questions or want more information concerning this Notice of Privacy Practices, please contact your Program Director or the Chief Evaluation and Planning Officer, St. John’s Community Services, 2201 Wisconsin Avenue NW, Suite C-150, Washington DC, 20007, 202- 237-6500.