Family & Children Services: Notice of Privacy Practices
Effective April 14, 2003

PDF available

This notice describes how medical information about you may be used and disclosed and how you can get access to your medical information. Please review it carefully. If you have any questions about this Privacy Notice, please contact our Privacy Coordinator at (408) 292-9353.

I.    Introduction
This Notice of Privacy Practices describes how Family & Children Services (F&CS) may use and disclose your Protected Health Information (PHI) for purposes permitted or required by law. PHI means health information (including identifying information) we collected from you or your health care providers, health plans, employer or health care clearinghouse.  It may include information about your past, present or future physical or mental health or condition, the provision of your health care, and payment for your health care services. This Notice also describes our obligations to protect your health information and your rights and how you may exercise these rights regarding your health information.

F&CS is required to maintain the privacy of your health information and to provide you with this Notice of Privacy regarding our legal duties and privacy practices.  Family & Children Services programs that collect or maintain PHI will comply with the terms of this Notice.  However, we may modify the terms of this Notice at any time, and the new Notice will be effective for all PHI in our possession at the time, or received after, the change.  Upon request, F&CS will provide you with any revised Notice or you can review the Notice by accessing our web site @ www.fcservices.org.  F&CS will also post a copy of the current Notice at each of our sites where we provide care.

II.    How We Will Use and Disclose Your Health Information
F&CS will use and disclose your health information as described in each category listed below.  This notice only generally describes disclosures and does not describe all specific uses or disclosures of your PHI.

A.        Uses and Disclosures for Treatment, Payment and Operations
1. Treatment.  F&CS will use and disclose your health information to provide, coordinate or manage your health care and any related services.  For example, F&CS staff may discuss your health information among our staff at a case conference or to contact you to remind you of your appointment. 

2.  Payment. F&CS may use or disclose your health information to collect payment from a third party for your services.  For example, we may disclose your information to your health plan so they can take certain actions before your health plan approves or pays for your services.  These actions may include:

• determining of eligibility or coverage;  
• determining if the services were medically necessary;  
• determining if the services were appropriately authorized or certified; or
• ensuring the appropriateness of your care, or to justify the charges for your care.  For example, your health plan may ask us to share your health information in order to determine if the plan will approve additional visits to your therapist. 

F&CS may also disclose your health information to another health care provider so they can bill you for services they provided to you.  For example, an ambulance service that transported you to the hospital.

3.  Health Care Operations.  F&CS may use and disclose your health information to conduct our normal business operations.  For example, these activities may include quality assessment and improvement, reviewing the performance or qualifications of our clinicians, training students in clinical activities, licensing, accreditation, business planning and development, and general administrative activities. We may combine health information of many of our clients to decide what additional services we should offer, what services are no longer needed, and whether certain treatments are effective.

We may also provide your health information to other health care providers or your health plan so they can provide certain health care services.  We will do so only if you have or have had a relationship with the other provider or health plan. For example, we may provide information about you to your health plan to assist them in their quality assurance activities.

4.  Fundraising Activities.  F&CS may use or disclose health information about you to contact you about raising money for our programs, services and operations.  If you do not want us to contact you for fundraising purposes, you must notify the Privacy Coordinator in writing at 950 W. Julian Street, San Jose, CA  95126.  Please state clearly that you do not want to receive any fundraising solicitations from us.

B.        Uses and Disclosures That May be Made Without Your Authorization, But For Which You Will Have an Opportunity to Object.

If asked, we will not confirm orally, in writing or through any other medium that you are our current or former client, with the exceptions listed below under “Persons Involved in an Individual’s Care.” 

1.  Persons Involved in Your Care.  F&CS may provide health information about you to someone who helps pay for your care or to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  We may also use or disclose your health information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures for this purpose to family or other individuals involved in your health care. 

F&CS may disclose your health information to a spouse, a family member, or a friend so that such person may assist in your care during emergency situations, if we determine that it is in your best interest.  We will only disclose information that is directly relevant to participation in your care. If it is not an emergency and you are unable to make health care decisions, we will disclose your health information to: 

• a person designated in accordance with an advance directive validly executed under state law,
• your guardian or other fiduciary if one has been appointed by a court, or
• if applicable, the state agency responsible for consenting to your care. 

C.        Uses and Disclosures That May be Made Without Your Authorization or Opportunity to Object.

1.  Emergencies.  F&CS may use and disclose your health information in an emergency treatment situation. For example, we may provide health information to a paramedic who is transporting you in an ambulance.  A clinician required to treat by law may use or disclose your PHI to treat you, even if they have attempted to obtain your authorization but were unable to do so.

2. As Required By Law.  F&CS will disclose health information about you when required to do so by federal, state or local law.

3.  To Avert a Serious Threat to Health or Safety.  F&CS may use and disclose health information about you to someone who is able to help prevent or lessen a serious and imminent threat to your health or safety, the health or safety of the public or another person.

4.  Public Health Activities.  F&CS may disclose health information about you as necessary for public health activities. For example to:

• report to public health authorities for the purpose of preventing or controlling disease, injury or disability;
• conduct public health surveillance or investigations;
• report child abuse or neglect;
• report certain events to the Food and Drug Administration (FDA) or to a person subject to the jurisdiction of the FDA including information about defective products or problems with medications;
• notify consumers about FDA-initiated product recalls;
• notify the appropriate government agency if we believe you have been a victim of abuse, neglect or domestic violence.  We will only notify an agency if we obtain your agreement or if we are required or authorized by law to report such abuse, neglect or domestic violence.

5.  Health Oversight Activities.  F&CS may disclose your health information to a health oversight agency for activities authorized by law. For example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs and benefits, compliance with civil rights laws and the health care system in general.

6.  Disclosures in Legal Proceedings.  F&CS may disclose your health information to a court or administrative agency when a judge or administrative agency orders us to do so.

7.  Law Enforcement Activities.  F&CS may disclose health information to a law enforcement official:

• In response to a court order, warrant, summons or similar legal process,
• To identify or locate a suspect, fugitive, material witness or missing person,
• To report a death that we believe may be the result of criminal conduct,
• Regarding criminal conduct occurring on the premises of our facility or to any staff member,
• To respond to a threat of an imminently dangerous activity by you against yourself or another person,
• The disclosure is otherwise required by law,
• To disclose health information about a client who is a victim of a crime, without a court order or without being required to do so by law, only if the disclosure has been requested by a law enforcement official and the victim agrees to the disclosure.  In the case of the victim’s incapacity, the following occurs: 
• the law enforcement official represents to us that (i) the victim is not the subject of the investigation and (ii) an immediate law enforcement activity to meet a serious danger to the victim or others depends upon the disclosure; and (iii) we determine that the disclosure is in the victim’s best interest. 

8.  Medical Examiners or Funeral Directors.  F&CS may provide health information about our consumers to a medical examiner or funeral directors as necessary to carry out their duties.

9.  Military and Veterans.  If you are member of the armed forces, F&CS may disclose your health information as required by military command authorities for determining your eligibility for benefits.  Finally, if you are a member of a foreign military service, we may disclose your health information to that foreign military authority. 

10.  National Security and Protective Services for the President and Others.  F&CS may disclose medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.  For example, so they may conduct special investigations or provide protection to the President or other authorized persons.

11.  Workers’ Compensation.  We may disclose health information about you to comply with the state’s Workers’ Compensation Law. 

III.    Uses and Disclosures of Your Health Information with Your Permission.
We will request your written authorization for uses and disclosures of your medical information that we did not identify in this Notice or for those not otherwise permitted by law. You have the right to revoke an authorization at any time.  If you revoke your authorization we will not make any further uses or disclosures of your health information under that authorization, unless we have already taken an action relying upon the uses or disclosures you have previously authorized.

IV.    Your Rights Regarding Your Health Information.

A.        Inspect and Copy.
You may request access to inspect or copy your health information maintained in our records, including clinical and billing records.  You must submit your request in writing to our Privacy Coordinator at 950 W. Julian Street, San Jose, CA  95126.  We may charge a fee for the cost of copying, mailing and supplies associated with your request.  In limited circumstances we may deny your request.  In some cases, you will have the right to have the denial reviewed by a licensed health care professional not directly involved in the original decision to deny access.  We will inform you in writing if the denial of your request may be reviewed.  Once the review is completed, we will honor the decision made by the licensed health care professional reviewer. 

B.         Amend.
You may ask us to amend your health information if you believe that it is incorrect or incomplete. To request an amendment, you must submit a written document to our Privacy Coordinator at 950 W. Julian Street, San Jose, CA 95126, and tell us why you believe the information is incorrect or inaccurate.  We will deny your request if:

• your request is not in writing or does not include a reason to support the request.
• the information was not created by us, unless the entity that created the health information is no longer available to make the amendment;
• the information is not part of the health information we maintain to make decisions about your care;
• the information is not part of the health information that you would be permitted to inspect or copy; or
• the information is accurate and complete.

If F&CS denies your request to amend, we will send you a written notice of the denial stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with the denial.  If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request. 

If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement.  In this case, we will attach the written request and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that is the subject of your request. 

C.        Accounting of Disclosures.
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee which we will notify you of in advance. Submit your request in writing to the Privacy Coordinator at 950 W. Julian Street, San Jose, CA 95126.  For your convenience, you may submit your request on a form called a “Request For Accounting,” which you may obtain from our receptionist.

D.        Request Restrictions. 
You may request restrictions on certain uses of your health information regarding treatment, payment or health care operations.  Make your request in writing to the Privacy Coordinator at 950 W. Julian Street, San Jose, CA  95126.  It must specify the information you wish restricted and how you want it restricted.  We are not required to agree to a restriction.  If we do agree, we will ask you to complete, sign and return a request for restriction form to the Privacy Coordinator.  When we agree to a restriction, F&CS will honor your request, unless we need to use that information to provide you with emergency treatment or until we receive notice from you that you no longer want the restriction..

E.         Request Confidential Communications.
You have the right to request that F&CS communicates with you about your health care only in a certain location or method.  For example, you may request that we contact you only at work.  You must make this request in writing to the Privacy Coordinator at 950 W. Julian Street, San Jose, CA  95126.  Your request must specify how or where you wish to be contacted.  F&CS will accommodate all reasonable requests.

F.         Paper Copy of this Notice. 
You have the right to get a paper copy of this Notice at any time.  To obtain a paper copy, you may call us and ask that a copy be sent to you or you can ask for one any time you are at our office.

VI.       Complaints.
You may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.  To file a complaint with us, contact our Privacy Coordinator responsible for receiving complaints at 950 W. Julian Street, San Jose, CA  95126, PrivacyCoordinator@fcservices.org, or (408) 292-9353.  All complaints must be submitted in writing.  Our Privacy Coordinator, will assist you with writing your complaint, if you request such assistance.  We will not retaliate against you for filing a complaint.

A violation by us of the federal law and regulations governing drug or alcohol abuse is a crime.  Suspected violations may be reported to the Unites States Attorney in the district where the violation occurs.  42 U.S.C. § 290dd-2 for federal law and 42 C.F.R., Part 2 for federal regulations governing confidentiality of alcohol and drug abuse patient records would provide more information.

Family & Children Services
950 W. Julian Street, San Jose, CA  95126
375 Cambridge Avenue, Palo Alto, CA  94306
1 West Campbell Avenue D40 & 41, Campbell, CA 95008