This notice describes how information about you and your treatment may be used and disclosed and how you can get access to your information. Please review this carefully.
During the course of providing services to you, Center for Youth Wellness (CYW) gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of mental health services to you, and payment for your services. This personal information is characterized as your “protected health information.” This Notice of Privacy Practices describes how CYW maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.
CYW is required by federal and state law to maintain the privacy of your protected health information. CYW is also required by law to provide you with this Notice of Privacy Practices that describes CYW’s legal duties and privacy practices with respect to your protected health information. CYW will abide by the terms of this Notice of Privacy Practices. CYW reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that it maintains, including protected health information already in its possession. If CYW changes its Notice of Privacy Practices, it will post a revised notice on its website at www.centerforyouthwellness.org.
CYW will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. CYW has prepared an authorization form for you to use that authorizes CYW to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. CYW then will not use or disclose your protected health information, except where it has already relied on your authorization.
CYW may, in its discretion, use or disclose your protected health without your written authorization in the following circumstances:
Your Care and Treatment – CYW may use or disclose your protected health information to provide you with or assist in your treatment, care and services.
Health Care Operations – CYW may use your protected health information for CYW’s health care operations. These uses and disclosures are necessary to manage CYW and to monitor our quality of services and care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff in caring for you.
Licensing and Accreditation – CYW may disclose your protected health information to any government or private agency, such as to the California Department of Health Services and the California Department of Social Services, responsible for licensing or accrediting CYW so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.
Disaster Relief- CYW may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.
CYW Workforce – CYW allows its Workforce to share protected health information (PHI) with one another to the extent necessary to permit them to perform their legitimate functions on the behalf of CYW. At the same time, CYW will work with its Workforce to restrict unnecessary or extraneous communications that will violate the rights of patients to have the confidentiality of their PHI maintained.
Business Associates -CYW may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, quality assurance, legal, or accounting services. CYW may disclose your protected health information to a Business Associate, as necessary, to allow the Business Associate to perform its functions on CYW’s behalf. CYW will have a contract with each Business Associate that obligates the Business Associate to maintain the confidentiality of your protected health information.
Research – CYW may disclose PHI for research purposes, provided that an outside Institutional Review Board overseeing the research approves the disclosure of the information without a written authorization.
Appointment Reminders – CYW may use or disclose your protected health information to remind you about appointments.
Organ and Tissue Donation- If you are an organ donor, CYW may use or release your protected health information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans- If you are a member of the armed forces, CYW may release your protected health information as required by military command authorities. CYW also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Workers’ Compensation- CYW may release protected health information for workers’ compensation or similar programs.
Inmates or Individuals in Custody- If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
Data Breach Notification Purposes- CYW may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.
CYW will disclose protected health information to outside persons or entities without your written authorization as required by law in the following circumstances:
Court Order; Order of Administrative Tribunal – CYW will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency.
Subpoena -CYW will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.
Law Enforcement Agencies – CYW will disclose protected health information to law enforcement agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons.
Coroner – CYW will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to notify next of kin; or to investigate deaths that may involve public health concerns, suspicious circumstances, child/elder abuse, or organ or tissue donation.
Child/ Elder Abuse Reporting – CYW will disclose protected health information about a youth or member of his/her family who is suspected to be the victim of child/elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain circumstances, CYW may disclose further protected health information about the youth and/or his/her family to aid the investigating agency in performing its duties. CYW will promptly inform the youth or his/her parent or guardian about any disclosure unless CYW believes that informing the youth or his/her parent or guardian would place the youth in danger of serious harm, or believes informing his/her parent or guardian would not be in the youth’s best interest.
Other Disclosures Required by Law – CYW will disclose protected health information about a youth and/or his/her family when otherwise required by law.
You have the following rights with respect to your protected health information. To exercise these rights, contact CYW at the following address:
CYW, 3450 3rd Street Building 2 Suite 201 , San Francisco, CA 94124 Attention: Privacy Officer
Right to Request Access – You have the right to inspect and copy your protected health information maintained by CYW. In certain limited circumstances, CYW may deny your request as permitted by law. However, you may be given an opportunity to have such denial reviewed by an independent licensed mental health professional. If CYW uses or maintains an electronic health record with respect to your protected health information, (1) you have a right to obtain from CYW a copy of such information in an electronic format and, if you choose, to direct CYW to transmit such copy directly to an entity or person designated by you, provided that any such choice is clear, conspicuous, and specific; and (2) any fee that CYW may impose for providing you with a copy of such information (or a summary or explanation of such information) if such copy (or summary or explanation) is in an electronic form will not be greater than CYW’s labor costs in responding to the request for the copy (or summary or explanation).
Right to Request Amendment – You have the right to request an amendment to your protected health information maintained by CYW. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an opportunity to submit a written statement disagreeing with the denial.
Right to Request Restriction – You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. CYW is not required to agree to your request, unless the disclosure is to a health plan for a payment or health care operation purpose and the medical information relates solely to a health care item or service for which we have been paid out-of-pocket in full. If CYW agrees to your request, it will comply with your request except in an emergency situation or until the restriction is terminated by you or CYW.
Right to Request Confidential Communications – You have the right to request that CYW communicate protected health information to the recipient by alternative means or at alternative locations.
Right to an Accounting – You have the right to receive an accounting of disclosures of your protected health information created and maintained by CYW over the six years prior to the date of your request or for a lesser period or three years in the case of PHI disclosed through our electronic health record for the purposes of either payment, treatment or health care operations. CYW is not required to provide an accounting of the following disclosures:
to carry out treatment, payment, and health care operations;
to respond to your requests for access to protected health information;
to aid in the identification or care of a patient.
Right to Receive a Copy of the Notice of Privacy Practices – You have the right to request and receive a copy of CYW’s Notice of Privacy Practices for Protected Health Information in written or electronic form. If your medical information is maintained in an electronic health record, you may obtain an electronic copy of your medical information and, if you choose, instruct us to transmit such copy directly to an entity or person you designate in a clear, conspicuous and specific manner. Our fee for providing you an electronic copy of your medical information will not exceed our labor costs in responding to your request for the electronic copy (or summary or explanation).
Right to Get Notice of a Breach – You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
Other Uses of Medical Information – To the extent required by law, when using or disclosing your medical information or when requesting your medical information from another Covered Entity, we will make reasonable efforts not to use, disclose or request more than a limited data set (as defined below) of your medical information or, if needed by us, no more than the minimum amount of medical information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. A limited data set means medical information that excludes the following items:
Postal address information, other than town or city, State, and zip code
Electronic mail addresses
Social security numbers
Medical record numbers
Health plan beneficiary numbers
Vehicle identifiers and serial numbers, including license plate numbers
Device identifiers and serial numbers
Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers
Biometric identifiers, including finger and voice prints
Full face photographic images and any comparable images
If you believe that your privacy rights have been violated, you may file a complaint with CYW, 3450 3rd Street Building 2 Suite 201., San Francisco, CA 94124 Attention: Privacy Officer. You also have the right to submit a complaint to the Secretary of the U.S. Department of Health and Human Services via the Office of Civil Rights, 90 7th Street, Suite 4-100, San Francisco, CA 94103; telephone: (415) 437-8310; Fax (415) 437-8311; TDD (415) 437-8311. CYW will not retaliate against you if you file a complaint.
If you have questions about this Notice of Privacy Practices or would like further information about your privacy rights, contact CYW, 3450 3rd Street Building 2 Suite 201, San Francisco, CA 94124 Attention: Privacy Officer.
The effective date of this Notice of Privacy Practices is September 1, 2013.