MESSAGE FROM
COVENANT COMMUNITY SERVICES, INC. (CCSI)
NOTICE OF PRIVACY
PRACTICES
Effective April 14,
2003
THIS NOTICE
DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
CCSI
is required by law to protect the privacy of the information
we have about you. We collect information about you when you
apply for benefits, and when doctors, clinics, dentists and
others bill us for your care. We also get medical information on
your treatment when we approve your care. We must give you this
Notice of how the law allows us to use and share your health
information and what your rights are.
HOW WE MAY USE AND
SHARE INFORMATION ABOUT YOU
CCSI
uses and shares information about you in operating
CCSI.
This information includes such things as your name, address,
personal facts, medical history, and medical care given to you.
We use this information and share it with others for the
following reasons:
For treatment:
You may need medical treatment that requires us to approve
care in advance. We will share information with doctors,
hospitals and others in order to get you the care you need.
For payment:
CCSI
and its agents review, approve, and pay for health care
claims sent to us for your medical care. When we do this, we
share information with the doctors, clinics, and others who bill
us for your care. And we may forward bills to other health plans
or organizations for payment.
For health care
operations:
CCSI
may use information in your health record to judge the
quality of health care you receive. We may also use this
information in audits or fraud investigations, or for planning
and general administration.
SOME OTHER WAYS WE
MAY SHARE YOUR INFORMATION
The law also allows
CCSI
to use or give out information we have about you for the
following purposes:
To contact you
about your benefits under
CCSI
For public health activities, such as reporting disease
outbreaks
For judicial and
administrative proceedings, such as lawsuits
For limited law
enforcement purposes, such as to locate a missing person
For research
studies that meet all privacy law requirements, such as research
related to preventing disease
To avoid a serious
and immediate threat to health or safety, such as a terrorist
attack
For national
security activities
To coroners,
medical examiners, and funeral directors
For organ
donations
For purposes
required by law, such as reporting abuse or neglect, or workers
compensation
To agencies that
oversee the health care system, for audits or investigations
In appeals of
decisions about health care claims paid or denied by
CCSI
To the federal
government when it is checking on how we are meeting privacy
laws
To other
government agencies that provide public benefits
To military
authorities, if you are a member of the armed forces
To create a
collection of information which can no longer be traced back to
you.
We may give out
health information about you to organizations, which help us in
our operations, such as by paying claims. If we do, we will make
sure that they protect the privacy of information we share with
them. Some state laws limit the sharing of information described
above. For example, there are special laws, which protect
information about HIV/AIDS status, mental health treatment,
developmental disabilities, and drug and alcohol abuse
treatment. We will obey these laws.
WHEN WRITTEN
PERMISSION IS NEEDED
Before
CCSI
will use your personal information for any reason not listed
above, it will get written permission from you. If you do give
us written permission to use or share your information for other
reasons, you may take back your permission in writing at any
time.
WHAT ARE YOUR
PRIVACY RIGHTS UNDER THE LAW?
You have the right
to ask us not to use or share your personal health care
information in the ways described above. We may not be able to
agree with your request.
You have the right
to ask us to contact you only in writing or at a different
address, post office box, or telephone number. We will accept
reasonable requests when necessary to protect your safety.
You and your
personal representative have the right to see and get a copy of
information which
CCSI
has about you. CCSI has
eligibility information, information about claims submitted to
us for payment, and some medical information, which we use to
approve services for you or manage your health care. You may be
charged a fee for the costs of copying and mailing records. We
may keep you from seeing all or parts of your records for
reasons allowed by law. If we do, we will give you information
on how to file an appeal of our decision.
If you believe
that certain information in our records about you is wrong, you
have the right to ask us to amend the records. We may deny your
request if the information is not created or kept by
CCSI, or is
already accurate and complete. If your request is denied, you
may send in a statement disagreeing with our decision which will
be kept with your records.
IMPORTANT
**** CCSI
DOES NOT HAVE COMPLETE COPIES OF YOUR
MEDICAL RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR
CHANGE YOUR MEDICAL RECORDS, PLEASE CONTACT YOUR DOCTOR, CLINIC,
OR MANAGED CARE PLAN.****
You have the right
to request a list of the times when we have shared your health
information after April 14, 2003. The list will tell you whom we
shared information with, when, for what reasons, and what
information was shared. The list will not include when we gave
information to you, or with your permission, or shared it for
treatment, payment, or health care operations.
You have a right
to get a paper copy of this Notice of Privacy Practices when you
request it. You can also find this Notice on our website when it
is available.
HOW DO YOU CONTACT
US TO USE YOUR RIGHTS OR TO COMPLAIN?
If you want to use
any of the privacy rights explained in this Notice, or, if you
believe that we have not protected your privacy and wish to
complain, please callor write us at:
Privacy Officer
Covenant Community
Services, Inc.
2828 H Street, Suite B-1
Bakersfield, CA 933061
(661) 326-8304
COMPLAINTS
You may file a
complaint by calling or writing the Privacy Officer, CCSI,
at the address and telephone number above.
You may also contact
the Secretary of the Department of Health and Human Services at
200 Independence venue, S.W., Room 615 F, Washington, D.C.
20201. Or you may call the U.S. Office of Civil Rights at
866-OCR-PRIV (866-627-7748) or 866-788-4989 TTY
CCSI
cannot take away
your health care benefits or do anything to hurt you in any way
if you choose to file a complaint or use any of the privacy
rights in this Notice.
If you have any
questions about this Notice, and want further information,
please contact the Privacy Officer, CCSI, at the address and
phone number above.
CHANGES TO NOTICE OF
PRIVACY PRACTICES
CCSI
must obey the Notice in effect on April 14, 2003. We have the
right to change our privacy practices. If we do make any
changes, we will revise this Notice and get it to you right
away.
COVENANT COMMUNITY SERVICES
HIPPA Policy
EMPLOYEE/FOSTER PARENT/CLIENT TRAINING CERTIFICATE
I,
________________________________________, certify that I have
received a copy of the HIPPA Privacy Awareness Policy. I have
read this plan and fully understand its content. Furthermore, I
understand that the HIPPA Privacy Awareness Policy is an aspect
of the organizations overall safety and employee wellness
program, and I agree to participate in future safety trainings
as directed by my supervisor. I also understand that it is my
responsibility to keep others and myself safe in the workplace
and I will strive toward this goal and end.
Date: _______________________________
Signed:
______________________________
cc: Employee/Child/Foster Parent
Employee/Child/Foster Parent File
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