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Privacy Policy

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

[45 CFR 164.520]

Background

The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights.

How the Rule Works

General Rule. The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy practices.

The Privacy Rule does not require the following covered entities to develop a notice:

  • Health care clearinghouses, if the only protected health information they create or receive is as a business associate of another covered entity. See 45 CFR 164.500(b)(1).
  • A correctional institution that is a covered entity (e.g., that has a covered health care provider component).
  • A group health plan that provides benefits only through one or more contracts of insurance with health insurance issuers or HMOs, and that does not create or receive protected health information other than summary health information or enrollment or disenrollment information.

See 45 CFR 164.520(a).

Content of the Notice. Covered entities are required to provide a notice in plain language that describes:

  • How the covered entity may use and disclose protected health information about an individual.
  • The individual’s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity.
  • The covered entity’s legal duties with respect to the information, including a statement that the covered entity is required by law to maintain the privacy of protected health information.
  • Whom individuals can contact for further information about the covered entity’s privacy policies.

The notice must include an effective date. See 45 CFR 164.520(b) for the specific requirements for developing the content of the notice.

A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices. See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C) for health plans, and 164.520(c)(2)(iv) for covered health care providers with direct treatment relationships with individuals.

 

Providing the Notice.

  • A covered entity must make its notice available to any person who asks for it.
  • A covered entity must prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits.
  • Health Plans must also:
  • Provide the notice to individuals then covered by the plan no later than April 14, 2003 (April 14, 2004, for small health plans) and to new enrollees at the time of enrollment.
  • Provide a revised notice to individuals then covered by the plan within 60 days of a material revision.
  • Notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years.
  • Covered Direct Treatment Providers must also:
  • Provide the notice to the individual no later than the date of first service delivery (after the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency treatment situation, make a good faith effort to obtain the individual’s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained.
  • When first service delivery to an individual is provided over the Internet, through e-mail, or otherwise electronically, the provider must send an electronic notice automatically and contemporaneously in response to the individual’s first request for service. The provider must make a good faith effort to obtain a return receipt or other transmission from the individual in response to receiving the notice.
  • In an emergency treatment situation, provide the notice as soon as it is reasonably practicable to do so after the emergency situation has ended. In these situations, providers are not required to make a good faith effort to obtain a written acknowledgment from individuals.
  • Make the latest notice (i.e., the one that reflects any changes in privacy policies) available at the provider’s office or facility for individuals to request to take with them, and post it in a clear and prominent location at the facility.
  • A covered entity may e-mail the notice to an individual if the individual agrees to receive an electronic notice.

See 45 CFR 164.520(c) for the specific requirements for providing the notice.

Organizational Options.

  • Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to develop more than one notice, such as when an entity performs different types of covered functions (i.e., the functions that make it a health plan, a health care provider, or a health care clearinghouse) and there are variations in its privacy practices among these covered functions. Covered entities are encouraged to provide individuals with the most specific notice possible.
  • Covered entities that participate in an organized health care arrangement may choose to produce a single, joint notice if certain requirements are met. For example, the joint notice must describe the covered entities and the service 3 OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 delivery sites to which it applies. If any one of the participating covered entities provides the joint notice to an individual, the notice distribution requirement with respect to that individual is met for all of the covered entities. See 45 CFR 164.520(d).

Frequently Asked Questions

To see Privacy Rule FAQs, click the desired link below:

FAQs on Notice of Privacy Practices

FAQs on ALL Privacy Rule Topics

(You can also go to http://answers.hhs.gov/cgi-bin/hhs.cfg/php/enduser/std_alp.php, then select “Privacy of Health Information/HIPAA” from the Category drop down list and click the Search button.)

Personal Rights

a. Each client shall have personal rights which include, but are not limited to, the following:

1. To confidentiality as provided for in Title 42 Chapter I, Subchapter A, Part 2 Sections 2.1 through 2.67, Code of Federal Regulations.

2. To be accorded dignity in personal relationships with staff and other persons.

3. To be accorded safe, healthy, and comfortable accommodations to meet their needs.

4. To be free from intellectual, emotional, verbal and/or physical abuse, exploitation, prejudice, or inappropriate sexual behavior.

5. To be informed by the program of the provisions of law regarding complaints including but not limited to the address and phone number of the Department.

6. To be afforded access to emergency medical or dental care.

7. To be free from discrimination based on race, color, ancestry, national origin, religion, creed, age, disability, sex, sexual orientation, gender identity or expression, marital status, medical condition, or military or veteran status.

8. To be afforded access to their client records.

9. To be treated for the life-threatening, chronic disease of substance use disorder with honesty, respect, and dignity, including privacy in treatment and in care of personal needs.

10. To be informed by the treatment provider of all the aspects of treatment recommended to the client, including the option of no treatment, risks of treatment, and expected result or results.

11. To be treated by treatment providers with qualified staff.

12. To receive evidence-based treatment.

13. To be treated simultaneously for co-occurring behavioral health conditions, when medically appropriate and when the treatment provider is authorized to treat cooccurring conditions.

14. To receive an individualized, outcome-driven treatment plan or progress notes.

15. To remain in treatment for as long as the treatment provider is authorized to treat the client.

16. To receive support, education, and treatment for their families and loved ones, if the treatment provider is authorized to provide these services.

17. To receive care in a treatment setting that is safe and ethical.

18. To be free from mental and physical abuse, exploitation, coercion, and physical restraint.

19. To be informed of these rights once enrolled to receive treatment, as evidenced by written acknowledgment or by documentation by staff in the clinical record that a written copy of these rights was given.

20. To receive ethical care that covers and ensures full compliance with the requirements set forth in Chapter 5 (commencing with Section 10500) of Division 4 of Title 9 of the California Code of Regulations and the alcohol and other drug program certification standards adopted in accordance with Section 18132, as applicable.

b. All clients shall be personally advised of, and given at admission, a copy of the rights specified in subsection (a)(1) through (20).

c. The program shall post a copy of the client rights in a location visible to all clients and the public.

d. Any program conducting research using clients as subjects shall comply with all standards of the California Research Advisory Panel and the federal regulations for protection of human subjects (Part 46 of Title 45 of the Code of Federal Regulations).