Notice of Privacy Practices – January 1, 2017 1
Jill’s House Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of
our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information
we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request.
We may charge a reasonable, cost-based fee. In some limited circumstances, we may say “no” to your
request, and you can ask that the denial be reviewed.
• Parents may access their minor child’s services record unless parental rights have been terminated, a
court order provides otherwise, or the minor’s treating physician or clinical psychologist has determined,
in the exercise of professional judgment, that the disclosure to the parent would be reasonably likely to
cause substantial harm to the minor or another person.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us
how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a
different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes”
unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
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• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to
the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care
operations, and certain other disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within
12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person
can exercise your rights and make choices about your health information.
• We will make sure that the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting the Jill’s House Privacy Official at
703-639-5683/[email protected].
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by
sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference
for how we share your information in the situations described below, talk to us. Tell us what you want us to do,
and we will follow your instructions if feasible or required by law.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in our directory
• Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious or unavailable, we may go
ahead and share your information if we believe it is in your best interest. We may also share your information
when needed to lessen a serious and imminent threat to health or safety.
In these cases, unless allowed by applicable law, we never share your information unless you give us written
permission:
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• Marketing purposes (except as described below)
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it, electronically or otherwise, with other professionals who are
treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition. We can
give out information for other treatment purposes, such as leaving an appointment reminder message.
Run our organization
We can use and share your health information to run our operations and engage in other health care
operations, improve your care, and contact you when necessary. We can share your information with our
business associates as described on this form. We may use your information to create de-identified
information to use for all lawful services.
Example: We use health information about you to manage your treatment and services. We may share health
information with other entities for their health care operations and other lawful purposes.
Bill for services
We can use and share your health information to bill and get payment from health plans, from you or other
entities, or to help others get payment.
Example: We give information about you to your health insurance plan so it will pay for your services. We may
give information to entities that help us collect payments. We may share your information with other entities
for their payment purposes.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public
good, such as public health and research. We have to meet many conditions in the law before we can share your
information for these purposes. For example, under state or other laws, we may need to obtain special approvals
to conduct research. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
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Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of
Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations and tissue banks.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual
dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official, or certain information relating to
inmates
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to and participate in lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a
subpoena. We can also share information when a protective order is in place.
Business associates
There are some health-related services provided through contracts with third parties, called “business
associates,” that may need the information to perform certain services on our behalf. Examples include
software or technology vendors we may utilize to provide technical support, attorneys providing legal services
to use, accountants, consultants, billing and collection companies, and others. When such a service is
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contracted, we may share your protected health information with such business associates and may allow our
business associates to create, receive, maintain or transmit your information on our behalf in order for the
business associate to provide services to us, or for the proper management and administration of the business
associate or to enable the business associate to fulfill its legal responsibilities. Business associates must
protect any health information they receive from, or create and maintain on our behalf. In addition, business
associates may re-disclose your health information for their own proper management and administration, to
fulfill their legal responsibilities, and to business associates that are subcontractors in order for the
subcontractors to provide services to the business associate. The subcontractors will be subject to the same
restrictions and conditions that apply to the business associate. Whenever such an arrangement involves the
use or disclosure of your information to our business associate, we will have a written contract with our
business associate that contains terms designed to protect the privacy of your information.
De-identified information
We may use or disclose your health information to create de-identified information or limited data
sets, and may use and disclose such information as permitted by law.
Inmates
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we
may release information about you to the correctional institution or law enforcement official as
permitted by applicable laws and rules.
Marketing
We may use and disclose your protected health information to communicate face-to-face with you to
encourage you to purchase or use a product or service, or to provide a promotional gift of nominal
value to you. We may also contact you to provide appointment reminders or information about
treatment alternatives or other health-related benefits and services that may be useful to you.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• While we take privacy and security very seriously, sometimes things go wrong. We will let you know
promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change
your mind.
• We will comply with state law. We will obtain your written consent for certain disclosures if your consent
is required under state law.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new
notice will be available upon request, in our office, and on our web site.
Effective Date
The effective date of this Notice is January 1, 2017. This Notice of Privacy Practices applies to Jill’s House, Inc.
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