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.
Legal Duty of Avenues:
Avenues is required by State and Federal laws to maintain the privacy of your medical information and other personal information in our possession, otherwise known as "protected health information" (PHI).
Avenues is also required to give each consumer this notice of our privacy practices, our legal duties and your rights as an active recipient of services through Avenues.
Avenues reserves the right to change our privacy practices, and the terms of this notice, at any time, according to applicable law. Whenever a change is made, you will receive an updated copy.
Protected Health Information:
Protected health information is defined as "any information that is created or maintained by Avenues that relates to past, present or future physical or mental health conditions which identifies an individual". Examples of protected health information can include your name, address, social security number, birth date, date of services, telephone number, fax number, medical reports or diagnostic code.
Except as described below, Avenues will not disclose any of your protected health information to any source unless you specifically authorize us to do so. Authorization will be in the form of a signed Release of Information Form. The release of information refers to various modes including written , verbal and electronic transfer of your "PHI".
Example of reason to disclose "PHI": Avenues may disclose information to your funding source, residential program or primary care giver for the purpose of coordinating services and monitoring the quality of these services.
Reasons for disclosing PHI without your authorization:
Treatment: Avenues may disclose your protected health information to a doctor or hospital which asks for it to assist them in providing you with necessary emergency treatment.
Litigation or When Required by Law: Your protected health information may be disclosed in response to a court order, warrant, subpoena or whenever required by law.
Family Member Responsible for Your Care: In the event that you are not able to care for yourself, and require the assistance of a parent, sibling, etc., we will release "protected health information", as needed, to the designated individual.
Public Health and Communicable Disease Reporting: Avenues may release your "PHI" in order to prevent or control disease, injury, disability, or to report child abuse or any type of suspected abuse or neglect.
Your Rights
You have the right to inspect or obtain a copy of your "PHI" from Avenues.
You must make this request, in writing to obtain a copy of or access to your "PHI". This request should be sent the Agency Privacy Officer.
Avenues will act upon your request within 30 days after receipt of the request. Avenues may charge you a reasonable fee to process and fulfill your request. If your request is denied, Avenues must provide, in writing, the reason for the denial.
You have the right to request restrictions on the use or disclosure of your "PHI". Any such request must be submitted in writing to the Avenues Privacy Officer. Avenues is not required to agree to these restrictions and in some cases may be prohibited from agreeing to them. If Avenues does not agree to the restrictions, you will receive a written notification.
You have the right to receive an accounting of disclosures of your information made by Avenues.
You have a right to receive a copy of this notice. This can be requested, at any time.
You have the right to request that Avenues communicate with you about your "PHI" by using alternative means or an alternative location, if the usual disclosure could endanger you. This request must be made in writing and clearly state why the information could endanger you unless communicated as you request.
Questions or Complaints
Contact Person:
Avenues Privacy Officer
Kim McSurdy
Address: 2 Park Street
Pottsville, PA 17901
Phone #: 570-622-7920
Fax#: 570-622-9271
E-mail: kmcsurdy@avenuesofpa.org
If you believe your privacy rights have been violated, you can file a complaint with the Avenues Privacy Officer: Kim McSurdy 570-622-7920, ext. 24 or with the Secretary of the United States Dept. Of Health and Human Services: 866-627-7748. There will be NO retaliation for filing a complaint.
I,______________________________(please print) understand that Avenues may use and disclose protected health information necessary for the provision of services, coordination of services or payment for services provided.
I verify that I have received a copy of the document entitled Privacy Notice which provides a complete description of potential uses and disclosures of my protected health information.
I understand that Avenues reserves the right to change its privacy practices and will send any revised notice to the address I’ve provided.
____________________________________ __________________
Signature Date
