Privacy Policy

Notice of Privacy Practices
Effective Date: April 14, 2003
Updated February, 2010

Notice of Privacy Practices

This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and
disclosures of protected health information that we may make. It also describes your rights to
access and control your protected health information and certain obligations we have regarding
the use and disclosure of your protected health information.

Your “protected health information” is information about you created and received by us,
including demographic information, that may reasonably identify you and that relates to your
past, present or future physical or mental health or condition, or payment for the provision of
your health care.

We are required by law to maintain the privacy of your protected health information. We are
also required by law to provide you with this Notice of our legal duties and privacy practices
with respect to your protected health information and to abide by the terms of the Notice that is
currently in effect. However, we may change our notice at any time. The new revised Notice
will apply to all of your protected health information maintained by us. You will not
automatically receive a revised Notice. If you would like to receive a copy of any revised
Notice you should access our web site at www.ucfs.org, contact United Community & Family
Services, Inc. (“UCFS”) or ask at your next appointment.

How We May Use or Disclose Your Protected Health Information

UCFS provides services through a broad continuum of programs, including outpatient medical
services, behavioral health, dental, home health, adult day care, assisted living and residential
care.

UCFS will ask you to sign a consent form that allows UCFS to use and disclose your protected
health information for treatment, payment and health care operations. You will also be asked to
acknowledge receipt of this Notice.

The following categories describe some of the different ways that we may use or disclose your
protected health information. Even if not specifically listed below, UCFS may use and disclose
your protected health information as permitted or required by law or as authorized by you. We
will make reasonable efforts to limit access to your protected health information to those
persons or classes of persons, as appropriate, in our workforce who need access to carry out
their duties. In addition, if required, we will make reasonable efforts to limit the protected
health information to the minimum amount necessary to accomplish the intended purpose of
any use or disclosure and to the extent such use or disclosure is limited by law.

For Treatment - We may use and disclose your protected health information to provide
you with medical treatment and related services. Your protected health information may be
used for the purpose of providing protected health information to a treatment provider
involved in your care. If we are permitted to do so, we may also disclose your protected
health information to individuals or facilities that will be involved with your care after you
leave UCFS and for other treatment reasons. We may also use or disclose your protected
health information in an emergency situation.
For Payment - We may use and disclose your protected health information so that we can
bill and receive payment for the treatment and related services you receive. For billing and
payment purposes, we may disclose your health information to your payment source,
including an insurance or managed care company, Medicare, Medicaid, or another third
party payor. For example, we may need to give your health plan information about the
treatment you received so your health plan will pay us or reimburse us for the treatment, or
we may contact your health plan to confirm your coverage or to request prior authorization
for a proposed treatment. If any of your services are paid for by the State of Connecticut as
part of a grant, we may disclose your protected health information to support the services
we provided you under the grant.
For Health Care Operations - We may use and disclose your health information as
necessary for operations of UCFS, such as quality assurance and improvement activities,
reviewing the competence and qualifications of health care professionals, medical review,
legal services and auditing functions, and general administrative activities of UCFS. Your
health information may be used by UCFS to perform case management for State, Federal or
local funding sources. We may also use an external clinical record reviewer in connection
with our quality assurance activities. We may also disclose your health information to
students or trainees who learn at UCFS to improve certain skills.
Within UCFS - Your information may be used by any UCFS department as necessary for
treatment, payment and health care operations purposes so long as only the minimum
amount of information necessary is used by UCFS for the purposes of payment and health
care operations.
Business Associates - There may be some services provided by our business associates,
such as a billing service, transcription company or legal or accounting consultants. We may
disclose your protected health information to our business associate so that they can
perform the job we have asked them to do. To protect your health information, we require
our business associates to enter into a written contract that requires them to appropriately
safeguard your information.
Appointment Reminders - We may use and disclose protected health information to
contact you as a reminder that you have an appointment at UCFS.
Treatment Alternatives and Other Health-Related Benefits and Services - We may
use and disclose protected health information to tell you about or recommend possible
treatment options or alternatives and to tell you about health related benefits, services, or
medical education classes that may be of interest to you.
Individuals Involved in Your Care or Payment of Your Care - Unless you object, we
may disclose your protected health information to a family member, a relative, a close friend
or any other person you identify, if the information relates to the person’s involvement in
your health care to notify the person of your location or general condition or payment
related to your health care. In addition, we may disclose your protected health information
to a public or private entity authorized by law to assist in a disaster relief effort. If you are
unable to agree or object to such a disclosure we may disclose such information if we
determine that it is in your best interest based on our professional judgment or if we
reasonably infer that you would not object.
Public Health Activities - We may disclose your protected health information to a public
health authority that is authorized by law to collect or receive such information, such as for
the purpose of preventing or controlling disease, injury, or disability; reporting births,
deaths or other vital statistics; reporting child abuse or neglect; notifying individuals of
recalls of products they may be using; notifying a person who may have been exposed to a
disease or may be at risk of contracting or spreading a disease or condition.
Health Oversight Activities - We may disclose your protected health information to a
health oversight agency for activities authorized by law, such as audits, investigations,
inspections, accreditation, licensure and disciplinary actions.
Judicial and Administrative Proceedings - If you are involved in a lawsuit or a dispute,
we may disclose your protected health information in response to your authorization or a
court or administrative order. We may also disclose your protected health information in
response to a subpoena, discovery request, or other lawful process if such disclosure is
permitted by law.
Law Enforcement - We may disclose your protected health information for certain law
enforcement purposes if permitted or required by law. Examples include reporting gunshot
wounds; reporting emergencies or suspicious deaths; complying with a court order,
warrant, or similar legal process; or answering certain requests for information concerning
crimes.
Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations - We may release your protected health information to a coroner, medical
examiner, funeral director, or, if you are an organ donor, to an organization involved in the
donation of organs and tissues.
Research Purposes - Your protected health information may be used or disclosed for
research purposes, but only if the use and disclosure of your information has been reviewed
and approved by a special Privacy Board or Institutional Review Board, or if you provide
authorization.
To Avert a Serious Threat to Health or Safety - We may use and disclose your
protected health information when necessary to prevent a serious threat to your health or
safety or the health or safety of the public or another person. Any disclosure, however,
would be to someone able to help prevent the threat.
Military and National Security - If required by law, if you are a member of the armed
forces, we may use and disclose your protected health information as required by military
command authorities or the Department of Veterans Affairs. If required by law, we may
disclosure your protected health information to authorized federal officials for the conduct
of lawful intelligence, counter-intelligence, and other national security activities authorized
by law. If required by law, we may disclose your protected health information to
authorized federal officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special investigations.
Workers’ Compensation - We may use or disclose your protected health information as
permitted by laws relating to workers’ compensation or related programs.
Special Rules Regarding Disclosure of Mental Health, Substance Abuse and HIV-Related Information - Generally, we may disclose your protected health information for
treatment, payment or health care operations. For disclosures concerning protected health
information relating to care for mental health conditions, substance abuse, HIV-related
testing and treatment, or minors, certain special restrictions may also apply. For example,
we generally may not disclose this specially protected information in response to a
subpoena, warrant or other legal process unless you sign a special authorization or a court
orders the disclosure.
Mental health information.We will only disclose mental health information pursuant
to an authorization, court order or as otherwise required by law. For example, all
communications between you and a psychologist, psychiatrist, social worker and certain
therapists and counselors will be privileged and confidential in accordance with
Connecticut and Federal law.
Substance abuse treatment information.If you are treated in a specialized substance
abuse program, the confidentiality of alcohol and drug abuse patient records is
protected by Federal law and regulations. We may not disclose that you have received
treatment for alcohol or drug abuse or any information regarding your treatment,
unless:

You consent in writing;
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in a medical emergency or to
qualified personnel for research, audit, or program evaluation.
Violation of these Federal laws and regulations by us is a crime. Suspected violations
may be reported to appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by
a patient either at the substance abuse program or against any person who works for the
program or about any threat to commit such a crime. Federal laws and regulations do
not protect any information about suspected child abuse or neglect from being reported
under State law to appropriate State or local authorities.

HIV-related information.We may disclose HIV-related information as permitted or
required by Connecticut law. For example, your HIV-related information, if any, may
be disclosed without your authorization for treatment purposes, certain health oversight
activities, pursuant to a court order, or in the event of certain exposures to HIV by
personnel of UCFS, another person, or a known partner.
Minors.We will comply with Connecticut law when using or disclosing protected
health information of minors. For example, if you are an unemancipated minor
consenting to a health care service related to HIV/AIDS, venereal disease, abortion,
outpatient mental health treatment or alcohol/drug dependence, and you have not
requested that another person be treated as a personal representative, you may have the
authority to consent to the use and disclosure of your health information.

When We May Not Use or Disclose Your Protected Health Information

Except as described in this Notice, or as permitted by Connecticut or Federal law, we will not
use or disclose your protected health information without your written authorization.

Your written authorization will specify particular uses or disclosures that you choose to allow.
Under certain limited circumstances, UCFS may condition treatment on the provision of an
authorization, such as for research related to treatment. If you do authorize us to use or disclose
your protected health information for reasons other than treatment, payment or health care
operations, you may revoke your authorization in writing at any time by contacting UCFS’s
Privacy Officer. If you revoke your authorization, we will no longer use or disclose your
protected health information for the purposes covered by the authorization, except where we
have already relied on the authorization.

Psychotherapy Notes

A signed authorization or court order is required for any use or disclosure of psychotherapy
notes except to carry out certain treatment, payment, or health care operations and for use by
UCFS for treatment, for training programs, or for defense in a legal action.

Marketing

A signed authorization is required for the use or disclosure of your protected health
information for a purpose that encourages you to purchase or use a product or service except
for certain limited circumstances such as when the marketing communication is face-to-face or
when marketing includes the distribution of a promotional gift of nominal value provided by
UCFS.

Sale of Protected Health Information

A signed authorization is required for the use or disclosure of your protected health
information in the event that UCFS receives remuneration for such use or disclosure, except
under certain circumstances as allowed by Federal or Connecticut law.

Your Health Information Rights

You have the following rights with respect to your protected health information. The following
briefly describes how you may exercise these rights.

Right to Request Restrictions of Your Protected Health Information - You have the
right to request certain restrictions or limitations on the protected health information we use
or disclose about you. You may request a restriction or revise a restriction on the use or
disclosure of your protected health information by providing a written request stating the
specific restriction requested. You can obtain a Request for Restriction form from UCFS.
We are not required to agree to your requested restriction, unless it involves the disclosure
of protected health information to a health plan for purposes of carrying out payment or
health care operations that pertains solely to a health care item or service for which UCFS
has been paid out of pocket in full. If we do agree to accept your requested restriction, we
will comply with your request except as needed to provide you with emergency treatment.
If restricted protected health information is disclosed to a health care provider for
emergency treatment, we will request that such health care provider not further use or
disclose the information. In addition, you and UCFS may terminate the restriction if the
other party is notified in writing of the termination. Unless you agree, the termination of
the restriction is only effective with respect to protected health information created or
received after we have informed you of the termination.
Right to Receive Confidential Communications - You have the right to request a
reasonable accommodation regarding how you receive communications of protected health
information. You have the right to request an alternative means of communication or an
alternative location where you would like to receive communications. You may submit a
request in writing to UCFS requesting confidential communications. You can obtain a
Request for Confidential Communications form from UCFS.
Right to Access, Inspect and Copy Your Protected Health Information - You have the
right to access, inspect and obtain a copy of your protected health information that is used to
make decisions about your care for as long as the protected health information is maintained
by UCFS. To access, inspect and copy your protected health information that may be used to
make decisions about you, you must submit your request in writing to UCFS. If you request
a copy of the information, we may charge a fee for the costs of preparing, copying, mailing or
other supplies associated with your request. We may deny, in whole or in part, your request
to access, inspect and copy your protected health information under certain limited
circumstances. If we deny your request, we will provide you with a written explanation of
the reason for the denial. You may have the right to have this denial reviewed by an
independent health care professional designated by us to act as a reviewing official. This
individual will not have participated in the original decision to deny your request. You may
also have the right to request a review of our denial of access through a court of law. All
requirements, court costs and attorneys’ fees associated with a review of denial by a court are
your responsibility. You should seek legal advice if you are interested in pursuing your
rights through a court.
Right to Amend Your Protected Health Information - You have the right to request an
amendment to your protected health information for as long as the information is maintained
by or for UCFS. Your request must be made in writing to UCFS and must state the reason for
the requested amendment. You can obtain a Request for Amendment form from UCFS. If
we deny your request for amendment, we will give you a written denial including the
reasons for the denial and the right to submit a written statement disagreeing with the
denial. We may rebut your statement of disagreement. If you do not wish to submit a
written statement disagreeing with the denial, you may request that your request for
amendment and your denial be disclosed with any future disclosure of your relevant
information.
Right to Receive An Accounting of Disclosures of Protected Health Information - You have the right to request an accounting of certain disclosures of your protected health
information by UCFS or by others on our behalf. To request an accounting of disclosures,
you must submit a request in writing, stating a time period beginning on or after April 14,
2003 that is within six (6) years from the date of your request. The first accounting provided
within a twelve-month period will be free. We may charge you a reasonable, cost-based fee
for each future request for an accounting within a single twelve-month period. However,
you will be given the opportunity to withdraw or modify your request for an accounting of
disclosures in order to avoid or reduce the fee. In the event UCFS maintains an electronic
health record, an accounting of disclosures from the electronic health record related to
treatment, payment or health care operations will be made only for the three (3) year period
preceding the request.
Right to Obtain A Paper Copy of Notice - You have the right to obtain a paper copy of
this Notice, even if you have agreed to receive this Notice electronically. You may request a
copy of this Notice at any time by contacting UCFS. In addition, you may obtain a copy of
this Notice at our web site, www.ucfs.org.
Right to Complain - You may file a complaint with us or the Secretary of the Department
of Health and Human Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our Privacy Officer of your complaint. You
will not be penalized for filing a complaint and we will make every reasonable effort to
resolve your complaint with you.

United Community & Family Services, Inc.
34 East Town Street
Norwich, CT 06360
Attention: Sharon Laliberte - (860) 892-7042 x218