The Community Action Partnership has a limited right to use and/or disclose your Protected Health Information (PHI) for the purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Community Action Partnership (Agency) has established policies to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF WHEN AND WHY YOUR HEALTH
INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. The agency may use health information to coordinate or manage the provision of services to you, by this agency or by others. The Agency may use your health information to coordinate or manage your care and the provision of services within the Agency and with other individuals outside of the Agency involved in your care, such as your attending physician and other health care professionals. For example, certain service providers involved in your care need information about your medical condition in order to deliver appropriate services.

To Obtain Payment. The Agency may include your health information in invoices to collect payment from third parties for the services you receive through the Agency. For example, some health information is transmitted to the Area Agency on Aging and the Ohio Department of Development when billing transactions are conducted.

To Conduct Health Care Operations. The Agency may use and disclose health information for its own operations and as necessary to provide quality care or services to all of the Agency’s service recipients. Health care operations includes such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and consumers with information about treatment alternatives and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Review and auditing, including compliance reviews, medical reviews, legal
  services and compliance programs.
• Business planning and development including cost management and planning
  related analyses and formulary development.
• Business management and general administrative activities of the Agency.
• Fundraising for the benefit of the Agency, and reports to funding sources.

As an example, the Agency may use your health information to evaluate its staff performance, or combine your health information with other Agency consumers in evaluating how to more effectively serve all Agency consumers. Your health information may be disclosed to Agency staff and contracted personnel for training purposes, or used to contact you as a reminder regarding a visit to you, or to contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).

For Treatment Alternatives. The Agency may use and disclose your health information to tell you about or recommend possible service options or alternatives that may be of interest to you.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES WHEN YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED

When Legally Required. The Agency will disclose your health information when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health. The Agency may disclose your health information for public activities and purposes in order to:

• Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To Conduct Health Oversight Activities. The Agency may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Agency, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

In Connection With Judicial And Administrative Proceedings. The Agency may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes. As permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

• As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
• For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
• Under certain limited circumstances, when you are the victim of a crime.
• To a law enforcement official if the Agency has a suspicion that your death was the result of criminal conduct.
• In an emergency in order to report a crime.

In the Event of A Serious Threat To Health Or Safety. The Agency may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Agency, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions. In certain circumstances, the Federal regulations authorize the Agency to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker's Compensation. The Agency may release your health information for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated above, the Agency will not disclose your health information other than with your written authorization. If you or your representative authorizes the Agency to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Agency maintains:

Right to request restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Agency’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Agency is not required to agree to your request. If you wish to make a request for restrictions, please contact Community Action Partnership of the Greater Dayton Area, Attn.: Director of Resource Development.

Right to receive confidential communications. You have the right to request that the Agency communicate with you in a certain way. For example, you may ask that the Agency only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact: Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development. The Agency will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.

Right to inspect and copy your health information. Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your request. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development. If you request a copy of your health information, the Agency may charge a reasonable fee for copying and assembling costs associated with your request.

Right to amend health care information. You or your representative have the right to request that the Agency amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by the Agency. A request for an amendment of records must be made in writing to: Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development. The Agency may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by the Agency, if the records you are requesting are not part of the Agency‘s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of the Agency, the records containing your health information are accurate and complete.

Right to know what disclosures have been made. You or your representative have the right to request an accounting of disclosures of your health information made by the Agency for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. The Agency would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to a paper copy of this notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development.

DUTIES OF THE AGENCY
The Agency is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. The Agency is required to abide by the terms of this Notice as may be amended from time to time. The Agency reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If the Agency changes its Notice, the Agency will provide a copy of the revised Notice to you or your appointed representative.

WHERE TO FILE A COMPLAINT
You or your personal representative have the right to express complaints to the Agency and to the Secretary of the United States Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to the Agency should be made in writing to Community Action Partnership of the Greater Dayton Area, Attn.: Resource Development. The Agency encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 2201 or call 1-877-696-6775.

CONTACT PERSON
The Agency has designated the Director of Resource Development as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may
contact this person at: Community Action Partnership of the Greater Dayton Area, Attn: Resource Development.

EFFECTIVE DATE
This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Community Action Partnership of the Greater Dayton Area Attn.: Director of Resource Development
719 S. Main Street
Dayton, OH 45402