This notice describes Wayne ARC privacy practices and the privacy rights of people we serve. It will describe how information about you may be used and disclosed and how you can get access to this information.

The HIPAA (Health Insurance Portability and Accountability Act) Privacy rule DOES NOT CHANGE the way you get services from Wayne ARC, or the privacy rights you have always had under New York State Mental Hygiene Law. The Privacy rule adds some details about how you can exercise your rights.

PLEASE REVIEW THIS NOTICE CAREFULLY.
This notice is effective as of April 14, 2003.
Our Privacy Commitment to You:

Wayne ARC provides many different services to you. We understand that information about you and your family is personal. We are committed to protecting your privacy and sharing information only with those who need to know and are allowed to see the information to assure quality services for you. Wayne ARC is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. This notice tells you how Wayne ARC uses and discloses information about you. It describes your rights and what Wayne Arc's responsibilities are concerning information about you. When we use the word "you" in this Notice, we also mean your personal representative. Depending on your circumstances and in accordance with state law, this may mean your guardian, your health care proxy, or your involved parent, spouse, or adult child.

If you have questions about any part of this notice or if you want more information about the privacy practices at Wayne ARC please contact:
Wendy Varricchio Fletcher, Privacy Officer;
150 Van Buren Street, Newark, NY 14513
Phone: 315-331-7741
E-mail: varricchio-fletcherw@waynearc.org

Who will follow this notice:
All people who work for Wayne ARC will follow this notice. This includes employees, persons Wayne ARC contracts with who are authorized to enter information in your clinical record or need to review your record to provide services to you, and volunteers that Wayne ARC allows to assist you.

What information is protected:
All information we create or keep that relates to your health or care and treatment, including, but not limited to your name, address, birth date, social security number, your medical information, your individualized service plan, and other information (including photographs or other images) about your care in our programs is considered protected information. In this Notice, we refer to protected information as "clinical information". Clinical information is kept in "clinical records".

Your Clinical Information Rights:
Unless otherwise required by law, your clinical record is the physical property of Wayne ARC but the information in it belongs to you and you have the right to have your clinical information kept confidential. You have the following rights concerning your clinical information.

You have a right to see or inspect your clinical information and obtain a copy. Some exceptions apply, such as records regarding incident reports and investigations, and information compiled for use in court or administration proceedings. NOTE: Wayne ARC requires you to make your request for records in writing to the Privacy Officer and, in some instances, may charge you for copies.

If we deny your request to see your clinical information, you have the right to request a review of that denial. The Executive Director/designee will appoint a licensed health care professional to review the record and decide if you may have access to the record.

·You have the right to ask Wayne ARC to change or amend clinical information that you believe is incorrect or incomplete. We may deny your request in some cases, for example, if the record was not created by Wayne ARC or if after reviewing your request, we believe the record is accurate and complete.

·You have the right to request a list of the disclosures Wayne ARC has made of your clinical information. The list, however, does not include certain disclosures, such as those made for treatment, payment, and health care operations, or disclosures made to you or made to others with your permission.

·You have the right to request a restriction on uses or disclosures of your health information related to treatment, payment, health care operations and disclosures to involved family. Wayne ARC, however, is not required to agree to your request.

·You have the right to request that Wayne ARC communicates with you in a way that will help keep your information confidential. You may request alternate ways of communication with you or request that communications are forwarded to alternative locations.

You have the right to receive a paper copy of this notice. You may ask Wayne ARC staff to give you another copy or you may obtain one from our website at www.waynearc.org.

·To request access to your clinical information or to request any of the rights listed here, you may contact;
Wendy Varricchio Fletcher, Privacy Officer;
150 Van Buren Street, Newark, NY 14513
Phone: 315-331-7741
E-mail: varricchio-fletcherw@waynearc.org
We will require you to submit your requests in writing to the Privacy Officer.

NOTE: Other regulations may restrict access to HIV/AIDS information and federally protected drug and alcohol information. See any special authorizations or consent forms which will specify what information may be released and when, or contact the Privacy Officer listed above.

Our Responsibilities to You:

We are required to:
• Maintain the privacy of your clinical information in accordance with federal and state laws.
·• Give you this notice that tells you how we will keep your clinical information private.
• Tell you if we are unable to agree to a limit on the use or disclosure that you request.
• Carry out reasonable requests to communicate clinical information to you by special means or at other locations.
• Get your written permission to use or disclose your clinical information except for the reasons explained in this notice.
• We have the right to change our practices regarding the clinical information we keep. If practices are changed, we will tell you by giving you a new notice. Notices will be posted on our website: www.waynearc.org

How Wayne ARC Uses and Discloses Your Health Information?

Wayne ARC may use and disclose clinical information without your permission for the purposes described below. For each of the categories of uses and disclosures, we explain what we mean and offer an example. Not every use or disclosure is described, but all of the ways we will use or disclose information will fall within these categories.

• Treatment: Wayne ARC will use your clinical information to provide you with treatment and services. We may disclose clinical information to doctors, nurses, psychologists, social workers, and other Wayne ARC personnel, volunteers or interns who are involved in providing you care. For example, involved staff may discuss your clinical information to develop and carry out your individualized service plan (ISP) and Individualized Educational Plan (IEP). Other Wayne ARC staff may share your clinical information to coordinate different services you need, such as medical tests, respite care, transportation, etc. We may also need to disclose your clinical information to your service coordinator and other providers outside of Wayne ARC who are responsible for providing you with the services identified in your ISP or IEP or to obtain new services for you.

Appointment Reminders: We may use and disclose clinical information to contact you as a reminder that you have an appointment for treatment or services at one of our programs.

• Payment: Wayne ARC will use your clinical information so that we can bill and collect payment from you, a third party, an insurance company, Medicare or Medicaid or other government agencies. For example, we may need to provide the NYS Department of Health or Medicaid with information about the services you received in our agency or through one of our Home and Community Based Services (HCBS) programs so they will pay us for the services. In addition, we may disclose your clinical information to receive prior approval for payment for services you may need. Also, we may disclose your clinical information to the US Social Security Administration, the Department of Health or other governmental agencies to determine your eligibility for coverage or your ability to pay for services.

• Health Care Operations: Wayne ARC will use clinical information for administrative operations. These uses and disclosures are necessary to operate Wayne ARC programs and residences and to make sure all consumers receive appropriate, quality care. For example, we may use clinical information for quality improvement to review our treatment and services and to evaluate the performance of our staff in caring for you.

We may also disclose information to clinicians and other personnel for on-the-job training. We will share your clinical information with other Wayne ARC staff for the purposes of obtaining legal services from our attorneys, conducting fiscal audits, and for fraud and abuse detection and compliance through our Continuous Improvement Department. We will also share your clinical information with NYS Office of Mental Retardation and Developmental Disabilities (OMRDD) staff to resolve complaints or objections to your services. We will also share your clinical information with our funding and regulatory oversight agencies including, but not limited to, OMRDD, New York State Commission on Quality of Care, Child Protective Services, Mental Hygiene Legal Services (MHLS), State Education Department and Department of Health to report serious incidents, fraud and abuse detection, fiscal audits, and program certification and compliance. We may also disclose clinical information to our business partners who need access to the information to perform administrative or professional services on our behalf.

Other Uses and Disclosures that Do Not Require your Permission:
In addition to treatment, payment and health care operations, Wayne ARC will use your clinical information without your permission for the following reasons:
• When we are required to do so by federal or state law;
• For public health reasons, including prevention and control of disease, injury or disability, reporting births and deaths, reporting child abuse or neglect, reporting reactions to medication or problems with products, and to notify people who may have been exposed to a disease or are at risk of spreading the disease;
• To report domestic violence and adult abuse or neglect to government authorities if necessary to prevent serious harm;
• For health oversight activities, including audits, investigations, surveys and inspections, and licensure. These activities are necessary for government to monitor the health care system, government programs, and compliance with civil rights laws. Health oversight activities do not include investigations that are not related to the receipt of health care or receipt of government benefits in which you are the subject;
• For judicial and administrative proceedings, including hearings and disputes. If you are involved in a court or administrative proceeding we will disclose clinical information if the judge or presiding officer orders us to share the information;
• For law enforcement purposes, in response to a court order or subpoena, to report a possible crime, to identify a suspect or witness or missing person, to provide identifying data in connection with a criminal investigation, and to the district attorney in furtherance of a criminal investigation of client abuse;
• Upon your death, to coroners or medical examiners for identification purposes or to determine cause of death, and to funeral directors to allow them to carry out their duties;
• To organ procurement organizations to accomplish cadaver, eye, tissue, or organ donations in compliance with state law;
• For research purposes when you have agreed to participate in the research and the Privacy Oversight Committee has approved the use of the clinical information for the research purposes;
• To prevent or lessen a serious and imminent threat to your health and safety or someone else's;
• To authorized federal officials for intelligence and other national security activities authorized by law or to provide protective services to the President and other officials.
• To correctional institutions or law enforcement officials if you are an inmate and the information is necessary to provide you with health care, protect your health and safety or that of others, or for the safety of the correctional institution.
• To governmental agencies that administer public benefits if necessary to coordinate the covered functions of the programs.
• For marketing: We may use information about where you live to contact you to notify you of new services Wayne ARC provides.

Uses and Disclosures that Require Your Agreement:
Wayne ARC may disclose clinical information to the following persons if we tell you we are going to use or disclose it and you agree or do not object:
• To family members and personal representatives who are involved in your care if the information is relevant to their involvement and to notify them of your condition and location; or
• To disaster relief organizations that need to notify your family about your condition and location should a disaster occur.
• For fundraising purposes, we may disclose information to a charitable program that assists us in fundraising with your permission.

Authorization Required For All Other Uses and Disclosures:

• For all other types of uses and disclosures not described in this Notice, Wayne ARC will use or disclose clinical information only with a written authorization signed by you that states who may receive the information, what information is to be shared, the purpose of the use or disclosure and an expiration for the authorization. Written authorizations are always required for use and disclosure for marketing purposes, such as Agency newsletters and press releases.

Note: If you cannot give permission due to an emergency, Wayne ARC may release clinical information in your best interest. We must tell you as soon possible after releasing the information.

You may revoke your authorization at any time. If you revoke your authorization in writing we will no longer use or disclose your clinical information for the reasons stated in your authorization. We cannot, however, take back disclosures we made before you revoked and we must retain clinical information that indicates the services we have provided to you.

Changes to this Notice:
We reserve the right to change this notice. We reserve the right to make changes to terms described in this notice and to make the new notice terms effective to all clinical information that Wayne ARC maintains. We will post the new notice with the effective date on our website at www.waynearc.org and in our facilities. In addition, we will offer you a copy of the revised notice at your next scheduled service planning meeting.

Complaints:
If you believe your privacy rights have been violated, you may file a complaint with:
Wendy Varricchio Fletcher, Privacy Officer;
150 Van Buren Street, Newark, NY 14513
Phone: 315-331-7741
E-mail: varricchio-fletcherw@waynearc.org

Or, you may contact the Secretary of the Department of Health and Human Services. You may call them at (877) 696-6775 or write to them at 200 Independence Ave. S. W., HHH Building Room 509H, Washington DC, 20201.
• You may file a grievance with the Office of Civil Rights by calling or writing Region II - US Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York 10278, Voice Phone (212) 264-3313, Fax (212) 264-3039, TDD (212) 264-2355.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.