THIS NOTICE DESCRIBES HOW MEDICAL AND DRUG AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

General Information

Information regarding your health care, including payment for health care, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320s et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Under these laws, Brandywine Counseling, Inc. (BCI) may not say to a person outside BCI that you attend the program, nor may BCI disclose any other information except as permitted by federal law.

BCI must obtain your written consent before it can disclose information about you for payment purposes. For example, BCI must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before BCI can share information for treatment purposes or for health care operations. However, federal law permits BCI to disclose information without your written permission:

1.      Pursuant to an agreement with a business associate;

2.      For research, audit or evaluations;

3.      To report a crime committed on BCI’s premises or against BCI personnel;

4.      To medical personnel in a medical emergency

5.      To appropriate authorities to report suspected child abuse or neglect

6.      As allowed by a court order

For example, BCI can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a business associate agreement in place.

Before BCI can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing.

Your Rights

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. BCI is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. BCI will accommodate such requests that are reasonable and will not request an explanation from you.  Under HIPAA you also have the right to inspect any copy your own health information maintained by BCI, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances. Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in BCI’s records, and to request and receive an accounting of disclosure of your health related information made by BCI during the six years prior to your request (not including disclosures made prior to April 14, 2003).  If you request a list of disclosures more than once in twelve (12) months, BCI can charge you a reasonable fee.  You may request to inspect your file, amend your file and/or obtain a listing of disclosures by submitting a written request to the Site Supervisor at the site you are receiving services.  You also have the right to receive a paper copy of this notice.

BCI’s Duties

BCI is required by law to maintain the privacy of your health of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.  BCI is required by law to abide by the terms of this notice.  BCI reserves the right to change the terms of this notice and make new notice provisions effective for all protected health information it maintains by first:

• Posting the revised notice in our sites;

• Making copies of the revised notice available upon request (either at our sites or through the contact person listed in this Notice); and

• Posting the revised notice on our website.

Complaints and Reporting Violations

If you think your privacy rights have been violated by BCI, or you want to complain to BCI about our privacy practices please submit written complaints to:

Michele Smelstoys

Brandywine Counseling, Inc.

24 Brookhill Drive

Newark, DE 19702

michele.smelstoys [at] brandywinecounseling.org

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.  If you file a complaint, we will not take any action against you or change our treatment of you in any way.

Violations of the Confidentiality Law by a program is a crime.  Suspected violations of the Confidentiality may be reported to the United States Attorney in the district where the violation occurs.

Contact

For further information contact:    Cindy Lobis

302-454-3020 ext. 24

Effective Date:  April 7, 2003

Acknowledgment

            I hereby acknowledge receiving a copy of this notice.

                                                                                                                                   

            ^{Patient’s Signature                                                                     Date}

                                                                                                                                                                                _{CQI 3/03}