• United Services receives and generates certain Protected Health Information about You that is stored in a medical record especially for You.
• Federal and State law requires that we maintain the privacy of Your Protected Health Information.
• Federal law requires that United Services provide You with this written Notice regarding its duties and practices in using Your Protected Health Information.
• United Services is required to abide by the terms of this Notice.
• United Services is required to notify You if it can’t abide by a requested restriction on how Your information is used or disclosed.
• United Services must accommodate reasonable written requests that You make for it to communicate Your Protected Health Information by alternative means or locations;
  and
• United Services reserves the right to change this Notice and have the changes apply not only to Protected Health Information acquired after the change in Notice, but have it also apply to Protected Health Information received before the change in Notice. Should our Notice be revised, we will post the revised Notice on our Web Site at www.unitedservicesct.org

• To provide treatment (e.g., discussions between caregivers for coordination and planning of Your care). Treatment means the provision of health care and related services, including coordinating and managing Your health care with a third party, consulting between health care providers, and referring You to another health care provider to receive care; and
• To conduct our administrative and business operations (e.g., activities relating to improving quality of care and/or evaluating our staff). Health Care Operations includes, but is not limited to, conducting quality improvement activities, reviewing the competence or qualifications of health care professionals, case management and care coordination, contacting of health care providers and clients with information regarding treatment alternatives, conducting or arranging for legal counsel, medical review and auditing functions, including fraud and abuse detection, business planning and development, management activities relating to compliance with State and Federal laws, resolution of internal grievances, and activities in connection with a sale of assets.

Federal law allows United Services to use and disclose Your Protected Health Information (except Psychotherapy Notes described below) for treatment, payment and health care operations without Your consent. However, since State law continues to require that we obtain Your consent for disclosure of Protected Health Information for payment purposes (e.g., Your insurer will require certain information to support our claim for payment), coordination of care with other providers (e.g., discharge planning and referrals), and the disclosure of certain sensitive information protected under State law, we will request Your consent for disclosure of Protected Health Information upon admission (or intake).

Required Disclosures to State Agencies. United Services may disclose Your Protected Health Information to the Department of Social Services, Department of Public Health, Department of Children and Families, Department of Mental Health and Addiction Services, Department of Health and Human Services or other agencies as required for payment and/or Funding of Service Provider.

Acknowledging Your Presence. Since we are publicly identified as a provider for the treatment of only psychiatric disorders and/or alcohol or drug abuse, we will not acknowledge Your presence in our facility or the fact that You receive treatment from us without Your specific written authorization. If we receive a request for disclosure of Your client records, we will not reveal that You are being treated without Your specific written authorization or unless otherwise permitted under the law.

Notification and Involvement in Your Care. We may communicate Protected Health Information: (a) to Your family member(s), legally authorized representative(s), and any other person identified by You, which is directly relevant to such person’s involvement in Your care or payment for Your care; and (b) to notify or assist in the notification of a family member, a personal representative, or any other person responsible for You. Such notification may include Your location, general condition, or death, but will not include confidential HIV-related, drug and alcohol or psychiatric information. If you are able, we will provide You with the opportunity to consent or object to such disclosure. If You are unable to object due to Your incapacity or an emergency circumstance, United Services, based upon its professional judgment, will make such disclosure if it determines that it is in Your best interest to do so. Such disclosure of Protected Health Information will be limited to information that is directly relevant to the recipient’s involvement with Your health care.

We may make disclosures of Your Protected Health Information to public or a private entity charged by law or its charter to assist in disaster relief efforts for the purposes of coordinating the disclosures described in (a) and (b) of the above paragraph.

Unless the Protected Health Information is protected by Federal and/or State drug, alcohol, psychiatric or HIV-related information confidentiality laws, we may use and disclose Your Protected Health Information without Your consent or without providing You the opportunity to object as follows:

• If the use or disclosure of Protected Health Information is required by law and is limited to the relevant requirements of the law (e.g. reporting an adverse incident in our facility);
• Disclosures made by law to State and Federal public health authorities (e.g., to report a defective medical device to the FDA);
• Disclosures made to government authorities for the purpose of reporting suspected abuse and neglect of children, the elderly and the mentally retarded;
• Disclosures to health oversight agencies authorized by law, in connection with audits, civil, administrative, or criminal investigations, licensure or disciplinary actions; or for monitoring compliance and quality, and program eligibility (e.g., Medicare, Medicaid, and State of Connecticut Department of Public Health, Department of Children and Families, and State Department of Mental Health and Addiction Services);
• Disclosures to persons exposed to a communicable disease if authorized by law to make such disclosure;
• Disclosures in connection with judicial and administrative proceedings in response to an order of the court or administrative tribunal, or in response to a lawfully issued subpoena;
• Disclosures to law enforcement if mandated by law (e.g., reporting gunshot wounds);
• Disclosures to law enforcement in the event of Your death if it is suspected that Your death was the result of criminal conduct;
• Disclosures to law enforcement if there is evidence of criminal conduct that occurred on United Services premises;
• Disclosures to the Office of State Medical Examiner as mandated by law (e.g., the occurrence of a suspicious death, contagious disease, and cremation);
• Disclosures to funeral directors as permitted by law;
• Disclosures to organ procurement organizations ("organ banks") in connection with organ donation and transplantation;
• Limited disclosures made in connection with record reviews in preparation for conducting research;
• Disclosures to persons reasonably able to prevent or lessen serious and imminent threat to the health or safety of a person or the public, or if necessary to apprehend an individual involved in a violent crime that we believe may have caused serious physical harm to You;
• Disclosures regarding armed forces personnel to appropriate military command authorities to assure proper execution of the military mission;
• Disclosures to Federal officials for protective services to the President or other governmental authorities;
• Disclosures to correctional institutions for the purpose of providing services to You or for the health and safety of the inmates or employees of the correctional institution; and
• Disclosures to comply with workers’ compensation or other programs that provide benefits for work-related injuries without regard to fault; and
• Disclosures that are otherwise permitted or required by law.

Protected Psychiatric Information. State law provides special protections when it comes to psychiatric information (e.g., communications between a psychiatrist, psychologist, licensed professional counselor, licensed social worker, licensed marriage and family therapist, and those working under their supervision, and his or her client). Except for treatment, or United Services business and administrative operations, psychiatric communications will not be disclosed without Your specific written consent, unless the disclosure is made: (i) to another health care Provider for the purpose of treatment and diagnosis (with notice to You); (ii) when there is substantial risk of imminent physical injury to You or others and the disclosure is necessary to place You in a treatment facility; (iii) to a court as part of a court ordered psychiatric examination; (iv) in a civil court proceeding if You introduce Your mental condition as an element of a claim or defense; (v) after Your death, when Your condition is introduced by a party claiming or defending through or as a beneficiary of You and a court finds it to be in the interests of justice to disclose such psychiatric information; (vi) to the Commissioner of the State Department of Public Health or the State Department of Mental Health and Addiction Services or Department of Children and Families in connection with an inspection or investigation; (vii) to individuals or agencies involved in the collection of fees for psychiatric services; (viii) to researchers who meet strict confidentiality standards; and (ix) to the State Department of Mental Health and Addiction Services or Department of Children and Families in connection with United Services receiving payment for services funded by such agency (with notice to You). You will not have access to any psychotherapy notes, as they are not part of the medical record.

Psychotherapy Notes are notes recorded by a mental health professional documenting or analyzing communications within a counseling session. Federal law treats Psychotherapy Notes differently than other psychiatric information by prohibiting disclosure without Authorization, unless it is disclosed for the reasons specified in (ii), (iii), (vi), (ix) above, and (iv) to the extent that the disclosure is made to defend a legal action against us brought by You. You may have access to the following psychiatric information: medication orders, treatment type and frequency, clinical test result, summaries of diagnosis, functional status, treatment plan symptoms, prognosis and progress to date.

Protected Drug and Alcohol Information. Federal law establishes certain protections for any client identifiable information relating to drug and alcohol treatment, treatment referral, research and/or rehabilitation, (but excludes protection for a diagnosis of drug overdose or alcohol intoxication or a diagnosis made solely for the purpose of providing evidence for use by law enforcement authorities). As a general rule, protected drug and alcohol information is confidential and may not be disclosed without Your authorization or pursuant to Federal law. Exceptions for disclosure of protected drug and alcohol information without Your authorization are as follows: (i) to medical personnel to the extent necessary to meet a bona fide medical emergency; (ii) to qualified personnel for the purpose of conducting research, management audits, program evaluation, provided You are not identified in any report; (iii) pursuant to a court order where good cause for such disclosure has been established; (iv) communications between a program and an entity and an affiliated covered entity having direct administrative control over our program; (v) to a business associate performing services on United Services’ behalf; (vi) limited communications with law enforcement regarding a crime committed or threatened by You on our premises; (vii) the reporting of incidents of suspected child abuse and neglect to the appropriate state authorities; and (viii) to the FDA when they assert that Your health may be threatened by an error in the manufacture, labeling, or sale of a product under FDA jurisdiction; and (ix) communications for the reporting of vital statistics, to authorized agencies investigating an individual’s cause of death, and to prevent multiple enrollments in certain programs as permitted or required by law. Please note that the exceptions do not apply to Psychotherapy Notes, unless one of the drug/alcohol exceptions also satisfies one of the exceptions for disclosure of Psychotherapy Notes without authorization.

Protected HIV-Related Information. Special rules under State law also limit the disclosure of HIV-related information. According to the rules, United Services may not disclose such information without Your specific written authorization, unless such disclosure is made: (i) to public health officials as required or allowed by State or Federal law; (ii) to a health care provider for the purpose of treatment; (iii) to a medical examiner to determine the cause of death; (iv) to a provider committee or another organization for the purpose of oversight or monitoring of United Services; (v) to a health care worker experiencing a significant occupational exposure to HIV infection; (vi) pursuant to a court order; (vii) to life and health insurers; (viii) to Your partner by a physician caring for You and Your partner if it is believed by the physician that Your partner is at significant risk for transmission; and (ix) if You are a minor, to Your parents or legal guardian, unless the physician determines there is cause (as defined by law) not to disclose to them.

• You have the right to request certain restrictions on the use of Your Protected Health Information for treatment, payment and our operations, disclosures to notify family and friends of Your location, general condition and/or death, and disclosures to notify others involved in Your care or payment of Your care. However, we are not required to honor such restrictions.
• You have the right to receive communications of Protected Health Information from the Provider by other means or locations;
• You have the right to inspect and have copied Your Protected Health Information for a fee, except psychotherapy notes, information collected for use in a court proceeding, or certain other information protected by Federal law governing clinical laboratories;
• You have the right to request to amend Protected Health Information so long as the amendment is accurate and complete;
• You have the right to revoke your Authorization and Consent except to the extent relied upon by notifying United Services in writing;
• You have the right to request an accounting of disclosures for a period of six years prior to the date of the request within 60-90 days of Your request (but not including disclosures that occurred prior to April 14, 2003; and
• You have a right to request a paper copy of the Notice of Privacy Practices.

Information and Complaints: For more information on how to exercise any of your rights regarding your Protected Health Information, please contact the Medical Records Department at United Services. You have the right to complain to United Services or the Secretary of the Department of Health and Human Services if You believe that Your privacy rights have been violated. To bring a complaint with us, You may contact the Privacy Officer at United Services, Inc., 1007 North Main Street, Dayville, CT 06241 or call (860) 774-2020. You will not be retaliated against for bringing the complaint.