Celine's Family Services, Inc.
one CHILD. ONE FAMILY.
Celine's Family Services, Inc.
4153 Flat Shoals Road, Decatur, GA 30034 | 5461 Hillandale Drive, Suite 130, Lithonia, GA 30058 | Warner Robins, GA
Phone 404-214-7116 | Fax 404-506-9439
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE DEPARTMENT AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice is effective April 14, 2003. It is provided to you pursuant to provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and related federal regulations. If you have questions about this Notice please contact the Legal Services Office at the address below. The Department of Human Resources is an agency of the State of Georgia responsible for numerous programs, which deal with medical and other confidential information. Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information, and the Department must comply with those laws. For situations where more stringent disclosure requirements do not apply, this Notice of Privacy Practices describes how the department may use and disclose your Protected Health Information (PHI) for treatment, payment, health care operations and for certain other purposes. This notice relates only to health information. It describes your rights to access and control your protected health information, and provides information about your right to make a complaint if you believe Celine’s Family Services, Inc. has improperly used or disclosed your PHI. PHI is information that may personally identify you and relates to your past, present, or future physical or mental health or condition and related health care services. Celine’s Family Services, Inc. is required abide by the terms of this Notice of Privacy Practices, and may change the terms of this notice, at any time. A new notice will be effective for all PHI that Celine’s Family Services, Inc. maintains at the time of issuance. Upon request, we will provide you with a revised Notice of Privacy Practices and by posting copies at our facilities. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by Celine’s Family Services, Inc., its administrative and clinical staff and others involved in your care and treatment for the purpose of providing health care services to you, and to assist in obtaining payment for your health care bills.
Treatment Your PHI may be used to provide, coordinate, or manage your health care and any related services, including coordination of your health care with a third party that has your permission to have access to your protected health information, such as for example, a health care professional who may be treating you, or to another health care provider such as a specialist or laboratory.
Payment Your PHI may be used to obtain payment for your health care services. For example, this may include activities that a health insurance plan requires before it approves or pays for health care services as; making a determination of eligibility or coverage, reviewing services provided to you for medical necessity and undertaking utilization review activities.
Health Care Operations Celine’s Family Services, Inc. may use or disclose your protected health information to support the business activities of the program, including, for example, but not limited to, quality assessment activities, employee review activities, training, licensing, and other business activities. Celine’s Family Services, Inc. may use a sign-in sheet at the registration desk at any facility where services are provided. You may be asked to provide your name and other necessary information, and you may be called by name in the waiting room when a staff member is ready to see you, and your protected health information may be used to contact you about appointments or for other operational reasons. Your PHI may be shared with third party “business staff members” who perform various activities that assist us in the provision of your services. Other uses and disclosures of your PHI will be made only with your written authorization, which you may revoke in writing at any time, except as permitted or required by law as described below. Permitted/Required Uses and Disclosures with Your Authorization/Opportunity to Object Celine’s Family Services, Inc. may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI unless you object, the Celine’s Family Services, Inc. may disclose protected health information for a facility directory or to a family member, relative, or any other person you identify, information related to that person’s involvement in your health care and may use or disclose PHI to notify or assist in notifying a family member, personal representative or other person responsible for your care of your location, general condition or death. Celine’s Family Services, Inc. may use or disclose your PHI to an authorized public or private entity in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. Objections may be made orally or in writing. Permitted/Required Uses and Disclosures without Your Authorization/Opportunity to Object
Celine’s Family Services, Inc. may use or disclose your protected health information without your authorization when required to do so by law; for public health purposes; to a person who may be at risk of contracting a communicable disease; to a health oversight agency; to an authority authorized to receive reports of abuse or neglect; in certain legal proceedings; and for certain law enforcement purposes. PHI may also be disclosed without your authorization to a coroner, medical examiner or funeral director; for certain approved research purposes; to prevent or lessen a threat to health or safety; and to law enforcement authorities for identification or apprehension of an individual. Required Uses and Disclosures Under the law, Celine’s Family Services, Inc. must make disclosures to you and when required by the Program Director/Clinical Team Leader of the Department of Health and Human Services to investigate or determine the Department’s compliance with the requirements of the Privacy Rule at 45 CFR Sections 164.500 et. Seq. The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights. You have the right to inspect and copy your PHI.
The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights. You have the right to inspect and copy your PHI. Upon written request, you may inspect and obtain a copy of protected health information about you for as long as Celine’s Family Services, Inc. maintains the PHI. This information includes medical and billing records and other records the program uses for making medical decisions about you. A reasonable, cost-based fee for copying postage and labor expense may apply. Under federal law you may not inspect or copy information complied in anticipation of, or for us in, a civil, criminal, or administrative proceeding, or PHI that is subject to a federal or state law prohibiting access to such information. You have the right to request restriction of your PHI. You may ask in writing that the Celine’s Family Services, Inc. not use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations, and not to disclose protected health information to family members or friends who may be involved in your care. Such a request must state the specific restriction requested and to whom you want the restriction to apply. Celine’s Family Services, Inc. is not required to agree to a restriction you request, and if the program believes it is in your best interest to permit use and disclosures of your PHI, your information will not be restricted, except as required by law. If Celine’s Family Services, Inc. does agree to the requested restriction, the program may not use or disclose your PHI in violation of that restriction, unless it is needed to provide emergency treatment.
You may have the right to request to receive confidential communications from us by alternative means or at an alternative location.
Upon written request, Celine’s Family Services, Inc. will accommodate reasonable requests for your provision of an alternative address or other method of contact. Celine’s Family Services, Inc. will not request an explanation from you as to the basis for the request. You may have the right to request amendment of your PHI.
If Celine’s Family Services, Inc. created your PHI, you may request in writing an amendment of that information for as long as it is maintained by Celine’s Family Services, Inc. The program may deny your request for an amendment, and if it does so will provide information as to any further rights you may have with respect to such denial. You have the right to receive an accounting of certain disclosures Celine’s Family Services, Inc. has made of your PHI. This rights applies only to disclosures for purposes other than treatment, payment or healthcare operations, excluding any disclosures Celine’s Family Services, Inc. made to you, to family members or friends involved in your care, or for national security, intelligence or notification purposes. Upon written request, you have the right to receive legally specified information regarding disclosures occurring after April 14, 2003, subject to certain exceptions, restrictions and limitations. Complaints related to use or disclosure of your PHI. You may complain to the Security of Health and Human Services if you believe your health information privacy rights have been violated. You may file a complaint in writing with the DHR Division, Office or Facility, which maintains your PHI, by mail to the following address: Executive Director HIPAA Privacy Coordinator, 2 Peachtree Street, NW 40th Floor, Atlanta, Georgia 30303-3159. You must state the basis for your complaint.