Notice of Privacy Practices

Effective Date: April 14, 2003

Purpose of the Notice of Privacy Practices

This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information that we may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information.

Your “protected health information” is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.

We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with notice of our legal duties and privacy practices with respect to your protected health information and to abide by the terms of the Notice that is currently in effect. However, we may change our notice at any time. The new revised Notice will apply to all of your protected health information maintained by us. You will not automatically receive a revised Notice. If you would like to receive a copy of any revised Notice you should access our web site at www.boysvillage.org, contact Boys and Girls Village Inc.. or ask at your next appointment.

How We May Use or Disclose Your Protected Health Information

Boys and Girls Village Inc. will ask you to sign a consent form that allows the Boys and Girls Village Inc. to use and disclose your protected health information for treatment, payment and health care operations. You will also be asked to acknowledge receipt of this Notice on the Consent and Acknowledgement Form.

The following categories describe some of the different ways that we may use or disclose your protected health information. Even if not specifically listed below, Boys and Girls Village Inc. may use and disclose your protected health information as permitted or required by law or as authorized by you. We will make reasonable efforts to limit access to your protected health information to those persons or classes of persons, as appropriate, in our workforce, who need access to carry out their duties. In addition, we will make reasonable efforts to limit the protected health information to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such disclosure is limited by law.

· For Treatment - We may use and disclose your protected health information to provide you with medical treatment and related services. Your protected health information may be used, for example, to communicate with the Department of Children and Families, a school, or a primary care physician to coordinate treatment. If we are permitted to do so, we may also disclose your protected health information to individuals or facilities that will be involved with your care after you leave the Boys and Girls Village Inc. and for other treatment reasons. We may also use or disclose your protected health information in an emergency situation.

· For Payment - We may use and disclose your protected health information so that we can bill and receive payment for the treatment and related services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid, or another third party payor. For example, we may need to give your health plan information about the treatment you received so your health plan will pay us or reimburse us for the treatment, or we may contact your health plan to confirm your coverage or to request prior authorization for a proposed treatment.

· For Health Care Operations - We may use and disclose your health information as necessary for operations of Boys and Girls Village Inc. such as quality assurance and improvement activities, reviewing the competence and qualifications of health care professionals, medical review, legal services and auditing functions, and general administrative activities of Boys and Girls Village Inc. For example, Boys and Girls Village Inc. will use or disclose protected health information during licensing and accrediting site visits.

· Business Associates - There may be some services provided by our business associates, such as a billing service, or legal or accounting consultants. We may disclose your protected health information to our business associate so that they can perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.

· Appointment Reminders - We may use and disclose protected health information to contact you as a reminder that you have an appointment at Boys and Girls Village Inc.

· Treatment Alternatives and Other Health-Related Benefits and Services - We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives and to tell you about health related benefits, services, or medical education classes that may be of interest to you.

· Fundraising Activities – We may use information about you to contact you in an effort to raise money for the Boys and Girls Village Inc. and its operations. A description of how to opt out of receiving any further fundraising communications will be included with any fundraising materials you receive from Boys and Girls Village Inc.

· Individuals Involved in Your Care or Payment of Your Care - Unless you object, we may disclose your protected health information to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care or payment related to your health care. In addition, we may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.

· Public Health Activities - We may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information such as for the purpose of preventing or controlling disease, injury, or disability, reporting births or deaths, reporting child abuse or neglect, notifying individuals of recalls of products they may be using, notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

· Health Oversight Activities - We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure.

· Judicial and Administrative Proceedings - If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process if such disclosure is permitted by law.

· Law Enforcement - We may disclose your protected health information for certain law enforcement purposes if permitted or required by law. For example, to report gunshot wounds; to report emergencies or suspicious deaths; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.

· Research Purposes – Boys and Girls Village Inc. does not engage in any research.

· To Avert a Serious Threat to Health or Safety - We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.

· Military and National Security - If required by law, if you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities or the Department of Veterans Affairs. If required by law, we may disclose your protected health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by law. If required by law, we may disclose your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

· Workers’ Compensation - We may use or disclose your protected health information as permitted by laws relating to workers’ compensation or related programs.

· Special Rules Regarding Disclosure of Mental Health, Substance Abuse, and HIV-Related Information and Information of Minors - For disclosures concerning protected health information relating to care for mental health conditions, substance abuse or HIV‑related testing and treatment and minors, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or a court orders the disclosure.

· Mental health information. Certain mental health information may be disclosed for treatment, payment and health care operations as permitted or required by law. Otherwise, we will only disclose such information pursuant to an authorization, court order or as otherwise required by law. For example, all communications between you and a psychologist, psychiatrist or social worker will be privileged and confidential in accordance with Connecticut and Federal law.

· Substance abuse treatment information. If you are treated in a specialized substance abuse program, your permission will be needed for certain disclosures, but not emergencies, certain reporting requirements and other disclosures specifically allowed under Federal law and regulations. Generally, we may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser, unless:

1. You consent in writing;

2. The disclosure is allowed by a court order; or

3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of these Federal laws and regulations by us is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the substance abuse program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

· HIV‑related information. We will disclose HIV‑related information as permitted or required by Connecticut law. For example your HIV-related protected health information, if any, may be disclosed in the event of a significant exposure to HIV-infection to personnel of Boys and Girls Village Inc., another person, or a known partner. Any use and disclosure for such purposes will be to someone able to reduce the outcome of the exposure and limited in accordance with Connecticut and Federal law.

· Minors. We will comply with Connecticut law when using or disclosing protected health information of minors. For example, if you are an unemancipated minor consenting to a health care service related to HIV/AIDS, venereal disease, abortion, or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the use and disclosure of your health information.

When We May Not Use or Disclose Your Protected Health Information

Except as described in this Notice, or as permitted by Connecticut or Federal law, we will not use or disclose your protected health information without your written authorization. If you do authorize us to use or disclose your protected health information for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting the Boys and Girls Village Inc. Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization.

Psychotherapy Notes

A signed authorization or court order is required for any use or disclosure of psychotherapy notes except to carry out certain treatment, payment, or health care operations and for use by Boys and Girls Village Inc. for treatment, for training programs, or for defense in a legal action.

Marketing

A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by Boys and Girls Village Inc..

Your Health Information Rights

You have the following rights with respect to your protected health information. The following briefly describes how you may exercise these rights.

· Right to Request Restrictions of Your Protected Health Information - You have the right to request certain restrictions or limitations on the protected health information we use or disclose about you. You may request a restriction or revise a restriction on the use or disclosure of your protected health information by providing a written request stating the specific restriction requested and to whom you want the restriction to apply. You can request a Restriction Request form from Boys and Girls Village Inc. We are not required to agree to your requested restriction. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted protected health information is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and Boys and Girls Village Inc. may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restriction is only effective with respect to protected health information created or received after we have informed you of the termination.

· Right to Receive Confidential Communications - You have the right to request a reasonable accommodation regarding how you receive communications of protected health information. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. You may submit a request in writing to Boys and Girls Village Inc. requesting confidential communications. You can request a Confidential Communications form from Boys and Girls Village Inc.

· Right to Access, Inspect and Copy Your Protected Health Information - You have the right to access, inspect and obtain a copy of your protected health information that is used to make decisions about your care for as long as the protected health information is maintained by Boys and Girls Village Inc. To access, inspect and copy your protected health information that may be used to make decisions about you, you must submit your request in writing to Boys and Girls Village Inc. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing or other supplies associated with your request. We may deny, in whole or in part, your request to access, inspect and copy your protected health information under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent health care professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs and attorney’s fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing your rights through a court.

· Right to Amend Your Protected Health Information - You have the right to request an amendment to your protected health information for as long as the information is maintained by or for Boys and Girls Village Inc. Your request must be made in writing to Boys and Girls Village Inc. and must state the reason for the requested amendment. You can request a form from Boys and Girls Village Inc. to request an amendment to your information. 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. We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.

· Right to Receive An Accounting of Disclosures of Protected Health Information - You have the right to request an accounting of certain disclosures of your protected health information by Boys and Girls Village Inc. or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning on or after April 14, 2003 that is within six (6) years from the date of your request. The first accounting provided within a twelve-month period will be free. We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be given the opportunity to withdraw or modify your request for an accounting of disclosures in order to avoid or reduce the fee.

· Right to Obtain A Paper Copy of 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 by contacting Boys and Girls Village Inc.. In addition, you may obtain a copy of this Notice at our web site, www.boysvillage.org.

· Right to Complain - You may file a complaint with us or the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you.

Boys and Girls Village Inc.

Michelle Morgan Herb

528 Wheelers Farms Road

Milford CT 06460

203-877-0300x176