This notice contains important information about Samaritan Daytop Village’s privacy practices. It describes how information about you may be used and disclosed and how you can get access to it. Please review it carefully.

I. What is this notice?

To run its substance abuse treatment programs, Samaritan Daytop Village must collect, maintain and use nonpublic personal information on clients who receive its services. We consider this information private and confidential and have policies and procedures in place to protect the information against unlawful use and disclosure. This notice describes what types of information we collect, explains when and to whom we may disclose it, and provides you with additional important information as to our legal duties and privacy practices.

At Samaritan Daytop Village, we collect the following types of information about you:

• Information we receive directly or indirectly (in writing, in person, by telephone or electronically) when you apply for treatment, are admitted to one of our programs or that we enter into your treatment record as we provide services to you. Examples of this information are: name, address, social security number, date of birth, drug screens, marital status, driver license number, medical and substance abuse history.
• Information about your relationship and transactions with us, (e.g., requests by you for treatment, correspondence, service encounters, diagnoses, eligibility information and appeal and grievance information).II. What is nonpublic personal information (NPI)?

II. What is nonpublic personal information (NPI)?

Nonpublic personal information (“NPI”) is information that identifies you as an individual and relates to your participation in treatment, your physical or mental health/condition, the provision of substance abuse treatment or healthcare to you, or payment to the agency for the provision of services provided to you.

III. How does Samaritan Daytop Village protect this information?

At Samaritan Daytop Village, we restrict access to NPI to those employees who need to provide care or services to you or are engaged in important agency operations. We maintain physical, electronic and procedural safeguards to protect your information against unauthorized access and use. For example, access to our treatment programs is limited to authorized personnel and we protect information we maintain electronically through use of a variety of technical tools. We also have established a Privacy Office, which is responsible for leading professional development, as well as developing and overseeing the implementation and enforcement of policies and procedures to safeguard client information against inappropriate access, use and disclosure, consistent with applicable law.

Information that Samaritan Daytop Village collects, uses and maintains on you is protected by two Federal laws: the Health Insurance Portability and Accountability Act (HIPAA) and the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2). Samaritan Daytop Village does not disclose NPI to anyone, except with your authorization or otherwise as permitted by law.

New York state law provides additional confidentiality protections in some circumstances. For example, New York law requires that generally Samaritan Daytop Village may not release the identity of a person tested for HIV or the results of an HIV-related test without consent.

Drug and alcohol records are especially protected and typically require your specific authorization for release of confidential information. The Federal confidentiality law (42 CFR) does not permit Samaritan Daytop Village to

• Inform a person outside Samaritan Daytop Village that you attend the program
• Disclose any information identifying you as an alcohol or drug abuser
• Disclose any other protected information except as permitted by federal law

IV. How can Samaritan Daytop Village use and disclose NPI without your permission?

Federal laws (42 CFR and HIPAA) permit Samaritan Daytop Village to use and disclose NPI without your authorization for the following purposes:

• Research. Under certain circumstances, we may use and disclose information about you for research purposes. For example, a research project may involve comparing the health and recovery of all clients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of information, trying to balance the research needs with the client’s need for privacy of healthcare information. Research reports may not identify you directly or indirectly.
• Audit and evaluation. We may disclose protected information to qualified personnel for conducting management audits, financial audits or programmatic evaluations. This may include disclosing protected information to state or local governmental agencies, third party payers and peer review agencies who perform utilization or quality assurance reviews and disclose this information only to Samaritan Daytop Village.
• Court order.
• For a crime committed on Samaritan Daytop Village premises or against a Samaritan Daytop Village personnel.
• To medical personnel in a medical emergency.
• To appropriate authorities to report suspected child abuse or neglect.
• To a business associate. Samaritan Daytop Village contracts with outside individuals and organizations that perform business services for us, such as billing, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your information with a business associate so it can perform a service on our behalf. Samaritan Daytop Village will limit the disclosure of your information to a business associate to the amount of information that is the minimum necessary for the individual/company to perform services for Samaritan Daytop Village. In addition, we will have a written contact in place with the business associate requiring it to protect the privacy of your information.
• To a public health authority in certain situations (such as reporting a birth, death or disease as required by law, as part of a public health investigation, to report child or adult abuse or neglect or domestic violence, to report adverse events such as product defects or to notify a person about exposure to a possible communicable disease) as required by law.
• To coroners, medical examiners and funeral directors for identifying a deceased person, determining cause of death, or carrying on their duties as authorized by law. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ donation and transplantation.
• Payment. We may disclose protected health information for use in obtaining payment for services provided or in other health care operations.

Note: Samaritan Daytop Village will not use or disclose more information for payment purposes than is necessary. This is known as using only the minimum necessary amount to accomplish the purpose of use or disclosure. We are accountable to the Secretary of Health and Human Services to safeguard (keep secure) and protect (keep private) our clients’ information.

Except for the conditions described above the Federal confidentiality law (42 CFR) does not permit Samaritan Daytop Village to use or disclose protected information for healthcare operations or payment without first obtaining your written consent. This means that Samaritan Daytop Village must obtain your written consent at the start of treatment before it can:

• Disclose information about you for payment purposes to a third party
• Disclose information for the purposes of treatment (referrals) and healthcare operations with another agency, organization, provider or organization.

V. How does Samaritan Daytop Village use or disclose NPI and for what purposes?

Here are some examples of what we do with the information we collect and the reasons it might be used:

Examples of how we will use your NPI for treatment.

Information obtained by our clinical or medical staff or any other member of your substance abuse treatment team will be recorded in a treatment record and used to determine your course of treatment. Information collected for treatment purposes helps our clients work with clinical staff to effectively manage substance abuse and related health conditions, to improve quality of life and prevent relapse. We also maintain records of our response to individuals (future clients) inquiring about or requesting services.

To assist you with receiving medication on a timely basis, we fax your prescriptions and e-mail identifying information to a pharmacy provider Chem Rx Pharmacy. To help you obtain medical attention promptly, we fax information to Project Samaritan Health Services and we fax your personal information between our facilities to facilitate your transfer, discharge and continuing care.

Examples of how we will use your NPI for payment.

We may bill Medicaid or a private healthcare plan for your care. The information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures or medication received. Administration of substance abuse treatment policies or contracts, which, where applicable, may involve: claims payment and management; utilization review and management; medical necessity review; coordination of care, benefits, and other services; program analysis and reporting; risk management and auditing.

Examples of how we will use your NPI for agency operations.

Information we maintain may be used for quality assessment and improvement activities; program development; quality of care reviews; utilization review; performance measurement and outcomes assessment. Quality assessment and improvement activities help us review and improve the services we provide to our clients. Other reasons for using NPI for operations include data and information systems management and performing mandatory licensing, regulatory compliance/reporting, and public health reporting activities, as well as responding to requests for information from regulatory authorities, reporting suspected or actual fraud or other criminal activity occurring at the agency and conducting litigation.

Note: Samaritan Daytop Village or any other agency on behalf of Samaritan Daytop Village will not use client identifiable information for fundraising or marketing purposes, nor will Samaritan Daytop Village engage in the sale of patient health information (PHI).

VI. What are your rights governing the information that Samaritan Daytop Village collects, uses and maintains on you?

Under the Federal privacy law (HIPAA) you have the following rights with respect to NPI:

• To receive confidential communications of private/health care information
• The right to amend protected information
• The right to a restriction of disclosure of PHI to a health plan for payment if services have been paid in full by the client for that visit
• To access, inspect or obtain a copy of your private/health care information
• To request to amend your private/health care information
• To receive an accounting of disclosures of your private/health care information
• To revoke authorization to use or disclose private/health care information except to the extent that action has already been taken
• To request communications of private/health care information by alternative methods
• To request restrictions on certain uses and disclosures of private/health care information. Please know that Samaritan Daytop Village is not required to agree to a requested restriction.
• To receive a paper copy of this notice.
• To be notified in case of a breach of your unsecured protected health information when it has been or is reasonably believed to have been accessed, acquired or disclosed as a result of a breach.

VII. What do you need to do to request other disclosures of your information?

Clients may ask Samaritan Daytop Village to disclose their protected information to other individuals or for reasons not described. For example, you may want a family member to have access to your records or treatment program staff or to be informed that you are receiving treatment or that you have left treatment. To authorize us to disclose any of your personal information to another person or organization, please contact your program Director to ask for a special authorization form. When you receive the form, fill it out and return it to your Program Director.

If you fill out a form and later change your mind about the authorization tell your Program Director or send a letter to Samaritan Daytop Village at the address listed below, letting us know that you would like to revoke the special authorization. Please provide your name, address, Social Security number and a telephone number where we can reach you in case we need to contact you about your request.

VIII. What does Samaritan Daytop Village do with your health information when you are no longer attending an agency treatment program?

Samaritan Daytop Village does not destroy your information when you leave treatment. This information is subject to legal retention requirements. Policies and procedures that protect that information against inappropriate use and disclosure apply regardless of your status as current or former client.

IX. How is this notice distributed?

We provide this notice to all individuals upon first contact with any of our treatment programs, when our confidentiality practices are materially changed and at other times as required by law. We reserve the right to change the terms of this notice and to make the provisions of the new notice effective for all client private information we maintain. Updates of this notice are distributed to Samaritan Daytop Village staff and can be requested by calling the Privacy Office at the number below. If you have questions about this notice, please contact your Program Director or the Privacy Office at the number below.

X. What should you do if you want to file a complaint or you wish to exercise your rights?

Violation of the Federal Confidentiality of Alcohol and Drug Abuse Patient Records law (42 CFR Part 2) by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.

If you believe your privacy rights under the Health Insurance Portability and Accountability Act (HIPAA) have been violated you can submit a written complaint to the agency’s Privacy Office at the address below. You may also complain to the Secretary for Health and Human Services if you believe your privacy rights have been violated. There will be no retaliation for filing a complaint. All complaints must be submitted in writing.

If you would like additional information on how to exercise your rights you may contact the Privacy Officer at the number below. You may obtain a special privacy complaint form from your Program Director or the Privacy Office listed below.

If you want to access current information about yourself maintained by Samaritan Daytop Village, contact your Program Director for a special form to make your request on. If you want to access information about yourself after you leave Samaritan Daytop Village write to the address below.

If you believe the information in your record is wrong or incomplete, contact your Program Director for a special form to request amendment or correction. If you are no longer at Samaritan Daytop Village, write to the address below. Where required by law, or if we are the source of a confirmed error, we will correct or amend the records we maintain on you (but not the records maintained by Project Samaritan Health Services).

To request an accounting of disclosures, write to the address below or ask your Program Director for a form specific to your request. To request an accounting of disclosures, please fill out the form carefully and return it to your Program Director or to the address below.

To request a restriction or limitation on information we use or disclose about you, or to request an alternative method or location for receiving information from us, write to the address below or ask your Program Director for a form specific to your request. Please fill out the form carefully and return it to your Program Director or to the address below.