Wings for Children & Families, Inc.

How We May Use and Disclose Health Information About You

• For Treatment

Wings may use health information about you to provide, coordinate or manage the services, supports and health care you receive from us and other providers. We may disclose health information about you to doctors, nurses, qualified mental retardation professionals (QMRPs), psychologists, social workers, direct support staff and other agency staff, volunteers and other persons who are involved in supporting you or providing care. We may consult with other health care providers concerning you and, as part of the consultation, share your health information with them. For example, staff may discuss your information internally within our agency (such as with a supervisor) to help develop and carry out your individual service plan. Staff may share information to coordinate needed services, such as medical tests, transportation to a doctor’s visit, etc. Staff may need to disclose health information to entities outside of Wings to obtain new services for you (for example, a Behavior Specialist agency). In all cases (except as required by law), if Wings is providing information to or consulting with providers outside of our own agency, we will not do so unless you have provided us with a release of information form for that provider indicating what information you wish to be shared.

• For Payment

Wings may use and disclose health information about you so we can be paid for the services we provide to you. This can include billing a third party payor, such as MaineCare or the Department Health & Human Services, Children's Behavioral Health Services (DHHS/CBHS), or your own insurance company. For example, we may need to provide MaineCare or DHHS/CBHS information about you or the services we provide to you so we will be reimbursed for those services, as well as information that ensures you are eligible for services through MaineCare and DHHS/CBHS.

• For Health Care Operations

Wings may use and disclose health information about you for our own operations. These are necessary for us to operate Wings and to maintain quality services for our clients. For example, we may use health information about you to review the services we provide and the performance of our employees supporting you. We also may use the information to study ways to more efficiently manage our agency, for licensing purposes, or for our own internal quality assurance program.

• How We Will Contact You

Unless you tell us otherwise in writing, we may contact you either by telephone or by mail at either your home or your workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate with you in a certain way or at a certain location (other than identified here), please see the section "Right to Receive Confidential Communications" of this Notice.

• Appointment Reminders

Wings may use and disclose health information about you to contact you to remind you of an appointment.

• Treatment and Service Alternatives

Wings may use and disclose health information about you to contact you about treatment and service alternatives that may be of interest to you. For example, we may use health information about you to determine if you should be included in mailings to our clients about support groups, workshops, behavioral health services, etc.

• Fundraising

Wings may use and disclose health information about you to raise funds for our agency. In all cases if Wings is providing information to or consulting with providers outside of our own agency in order to raise funds for the agency, we will not do so unless you have provided us with a release of information form detailing what information you are willing to have shared with that provider.

• Disclosures to Family and Others

Within the scope of the Rights of Recipients of Mental Health Services Who Are Children in Need of Treatment (Rights of Recipients), which is to be given to you at the onset of case management services, Wings will disclose to a parent/guardian, or any other person identified by you or your parent/guardian (if under age 18 or unless emancipated), health information about you that is directly relevant to that person’s involvement with the services and supports you receive or payment for those services and supports. For example, Wings will disclose health information about you to your parent/guardian (if client is under age 18 or with appropriate release if over age 18 or emancipated) for the purpose of helping to carry out your Individualized Service Plan (ISP), or to DHHS/CBHS or MaineCare for the purpose of carrying out their statutory obligations to provide and pay for services provided to you. With the exception of your parent/guardian (if under 18 or unless emancipated), DHHS/CBHS, MaineCare, your own insurance company, and where we are required to report health information by law, you (if age 18 or emancipated) or your parent/guardian (if under age 18) has the right to decide who else receives health information about you, and you or your parent/guardian (if under age 18 or unless emancipated) will be asked to sign a Release of Information form outlining who may receive information and the scope of the information to be provided. (Refer to Rights of Recipients, page 16, Section IX – Confidentiality of and Access to Mental Health Records.)

• Required by Law

Wings may use or disclose health information about you when we are required to do so by law. (Please refer to Rights of Recipients, Section IX. Confidentiality of and Access to Mental Health Records, Subsection J. Exceptions, pages 19-20.)

• Public Health Activities

Wings may disclose health information about you for public health activities and purposes. This includes reporting health information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.

• Victims of Abuse, Neglect or Domestic Violence

Wings may disclose health information about you to a government authority authorized by law to receive reports of abuse, neglect or domestic violence if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you or your parent/guardian; or, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.

• Health Oversight Activities

Wings may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefits programs, and entities subject to various government regulations.

• Judicial and Administrative Proceedings

Wings may disclose health information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal. We also may disclose health information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.

• Disclosures for Law Enforcement Purposes

Wings may disclose health information about you to a law enforcement official for law enforcement purposes:

• As required by law.
• In response to a court, grand jury or administrative order, warrant or subpoena.
• To identify or locate a suspect, fugitive, material witness or missing person.
• About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
• To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
• About crimes that occur at our facility.
• To report a crime in emergency circumstances.
• Coroners and Medical Exams

Wings may disclose information about you to funeral directors as necessary for them to carry out their duties.

• Funeral Directors

Wings may disclose information about you to funeral directors as necessary for them to carry out their duties.

• Organ, Eye or Tissue Donation

To facilitate organ, eye or tissue donation and transplantation, we may disclose health information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue. Wings would not provide this information without a signed release from you or your parent/guardian.

• Research

Under certain circumstances, we may use or disclose health information about you for research. Before we disclose health information for research, the research will have been approved through an approval process that evaluates the needs of the research project with your needs for privacy of your health information. We may, however, disclose health information about you to a person who is preparing to conduct research to permit them to prepare for the project, but no health information will leave Wings during that person’s review of the information.

• To Avert Serious Threat to Health or Safety

Wings may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.

• National Security and Intelligence

Wings may disclose health information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law.

• Protective Services for the President

Wings may disclose health information about you to authorized federal officials so they can provide protection to the President of the United States, certain other federal officials, or foreign heads of state.

• Inmates; Persons in Custody

Wings may disclose health information about you to a correctional institution or law enforcement official having custody of you. The disclosure will be made if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or (c) the safety, security and good order of the correctional institution.

• Workers Compensation

Wings may disclose health information about you to the extent necessary to comply with worker’s compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.

• Other Uses and Disclosures

Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying your Case Manager, their Clinical Supervisor or the Clinical Director – Wings - 900 Hammond Street, Suite 915 Bangor, ME 04401 in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.

Your Rights With Respect to Health Information About You

You have the following rights with respect to health information that we maintain about you.

• Right to Request Restrictions

You have the right to request that we restrict the uses or disclosures of health information about you to carry out treatment, payment or health care operations.

To request a restriction, you may do so at any time. If you request a restriction, you should do so to

Privacy Officer – Wings-900 Hammond Street, Suite 915, Bangor, ME 04401 (207) 941-2988

and tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and (c) to whom you want the limits to apply. We are not required to agree to any requested restriction. However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.

• Right to Receive Confidential Communications

You have the right to request that we communicate health information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication.

If you want to request confidential communication, you must do so in writing to

Clinical Director – Wings – 900 Hammond Street, Suite 915, Bangor, ME 04401.

Your request must state how or where you can be contacted. We will accommodate your request. However, we may also require an alternate address or other method to contact you.

• Right to Inspect and Copy

You have the right to inspect and obtain a copy of health information about you. (See Also Rights of Recipients, Section IX. Confidentiality of and Access to Mental Health Records, page 16.)

To inspect or copy health information about you, you must submit your request in writing to

Clinical Director – Wings – 900 Hammond Street, Suite 915, Bangor, ME 04401.

Your request should state specifically what health information you want to inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.

We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.

We may deny your request to inspect and copy health information if the health information involved is:

• Psychotherapy notes;
• Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding.

If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designed by us who was not directly involved in the denial. We will comply with the outcome of that review.

• Right to Amend

You have the right to ask us to amend health information about you. You have this right for so long as the health information is maintained by us.

To request an amendment, you must submit your request in writing to

Clinical Director – Wings – 900 Hammond Street, Suite 915 Bangor, ME 04401.

Your request must state the amendment desired and provide a reason in support of that amendment.

We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.

If we grant the request, in whole or in part, we will see your identification of and agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the health information by appending or otherwise providing a link to the amendment.

We may deny your request to amend health information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. Additionally, we may deny your request to amend health information if we determine that the information:

• Was not created by us, unless the person or entity that created the information is no longer available to act on the requested amendment;
• Is not part of the health information maintained by us;
• Would not be available for you to inspect or copy; or
• Is accurate and complete.

If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreement with our denial. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement (if any) and our rebuttal (if any) will then be appended to the health information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information or, at our election, we may include a summary of any of that information.

If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the health information involved.

You also will have the right to complain about our denial of your request.

• Right to an Accounting of Disclosures

You have the right to receive an accounting of disclosures of health information about you. The accounting may be for up to six (6) years prior to the date on which your request the accounting, but not before April 14, 2003.

Certain types of disclosures are not included in such an accounting:

• Disclosures to carry out treatment, payment and health care operations;
• Disclosures of your health information made to you;
• Disclosures that are incident to another use or disclosure;
• Disclosures that you have authorized;
• Disclosures for national security or intelligence purposes;
• Disclosures to correctional institutions or law enforcement officials;
• Disclosures that are part of a limited data set for purposes of research, public health, or health care operations (a limited data set is where things that would directly identify you have been removed);
• Disclosures made prior to April 14, 2003.

Some examples of disclosures that are not excluded are: worker’s compensation, subpoenas.

Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure of disclosures to a law enforcement official or to a health oversight agency.

To request an accounting of disclosures, you must submit your request in writing to

Privacy Officer – Wings – 900 Hammond Street, Suite 915 Bangor, ME 04401.

Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and may not include dates before April 14, 2003.

Usually we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.

There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.

• Right to Copy of this Notice

You have the right to obtain a paper copy of our Notice of Privacy Practices. You may request a copy of our Notice of Privacy Practices at any time.

You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site, http://www.wingsinc.org.

To obtain a paper copy of this notice, contact

Privacy Officer – Wings – 900 Hammond Street, Suite 915 Bangor, ME 04401 (207) 941-2988.

Our Duties

• Generally

Wings is required by law to maintain the privacy of health information about you and to provide individuals with notice of our legal duties and privacy practices with respect to health information.

We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

• Our Right to Change Notice of Privacy Practices

Wings reserves the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.

• Availability of Notice of Privacy Practices?

A copy of our current Notice of Privacy Practices will be posted on the employment law bulletin boards in each office maintained by Wings and you also may request a copy from personnel in any office of Wings. A copy of the current notice also will be posted on our web site, http://www.wingsinc.org.

At any time you may obtain a copy of the current Notice of Privacy Practices by contacting

Privacy Officer – Wings Bangor office – 900 Hammond Street, Suite 915, Bangor ME 04401 (207) 941-2988.

• Effective Date of Notice

The effective date of the notice will be stated on the first page of the notice.

• Complaints

You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint about privacy practices with us, contact

Privacy Officer – Wings Bangor office – 900 Hammond Street, Suite 915, Bangor, ME 04401 (207) 941-2988.

All complaints should be submitted in writing.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.

You will not be retaliated against for filing a complaint.

• Questions and Information

If you have any questions or want more information concerning this Notice of Privacy Practices, please contact

Privacy Officer – Wings – 900 Hammond Street, Suite 915, Bangor, ME 04401 (207) 941-2988.