AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES

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1 AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES SCOPE OF POLICY This policy applies to all agency staff members. Agency staff members include all employees, trainees, volunteers, consultants, students, contractors and subcontractors at the agency. STATEMENT OF POLICY The Arc of Monroe County shall review its Notice of Privacy Practices with people served no later than the date when they are formally enrolled into a program or service. We are required to verify that the person served or personal representative have received the notice. Copies of the current notice shall be maintained and readily available at all programs, sites and locations. If/when there is a material revision to the notice, a copy of the notice will be available for people at non-residential sites and they will be notified that it has been revised within 60 days of the revision. The Arc s notice of privacy practices shall be given to staff consistent with the policy on Employee Health Records. Please cross reference that policy. IMPLEMENTATION OF POLICY Program management is required to ensure the review with people served or their personal representative of the notice of privacy practices at the time of the enrollment. The Confirmation of receipt of notice of privacy practices should be filled out at this time (see attached). If signed, a copy must be maintained in the person s designated record set. If the person served or their personal representative choose not to sign the confirmation or sign it and fail to return it, management should clearly document in the person s designated record set when the notice was given to the person or their personal representative. The privacy officer will notify Arc management of any material change in the notice and will inform them when new notices need to be made available to people serve and when they need to be notified of the change. VIOLATIONS The agency s Privacy Officer has general responsibility for implementation of this policy. Members of our medical staff and agency staff who violate this policy will be subject to disciplinary action up to and including termination of employment or contract with The Arc of Monroe County. Anyone who knows or has reason to believe that another person has violated this policy should report the matter promptly to his or her supervisor or the

2 agency s Privacy Officer. All reported matters will be investigated, and, where appropriate, steps will be taken to remedy the situation. Where possible, The Arc of Monroe County will make every effort to handle the reported matter confidentially. Any attempt to retaliate against a person for reporting a violation of this policy will itself be considered a violation of this policy that may result in disciplinary action up to and including termination of employment or contract with The Arc of Monroe County. QUESTIONS If you have questions about this policy, please contact your department supervisor or the agency s Privacy Officer. It is important that all questions be resolved as soon as possible to ensure protected health information is used and disclosed appropriately. Effective date: 4/1/03 Revised: 8/04 Revised: 9/17/08 8/5/15

3 Confirmation of Receipt of Notice of Privacy Practices The Arc of Monroe County, NYSARC, Inc. Name of person served: Date: Program/Service: By signing below, I acknowledge that: I have reviewed The Arc of Monroe County s Notice of Privacy Practices I have had clarified any part of the Notice which was unclear or about which I had questions I have been informed of my right to request restrictions on the uses and disclosures of my protected health information for emergency situations or for the carrying out of treatment, payment, or operations, as proposed by The Arc The Arc is not obligated to agree to any restrictions on uses or disclosures that I request Person served Guardian* Please note: By signing the as guardian, I verify that I am the person s court-appointed legal guardian. If there is a legal guardian, no further signatures are required. Advocate* As advocate, please check the box which reflects your relationship with the person served: I am an involved Parent Spouse Adult child Adult sibling

4 Other: Please note: By signing as the person s advocate, I verify that I am acting on his/her behalf in regards to this notice and the specific privacy practices noted therein. Recibo del Aviso de Practicas Privadas The Arc of Monroe County, NYSARC, Inc. Nombre del cliente: Fecha: Programa/Servicio: Al firmar este documento, reconozco que: - He revisado el Aviso de Practicas Pivadas de la agencia. - He sido explicado sobre algunas partes del Aviso que no entendia y de las cuales tenia preguntas. - He sido informado de mi derecho a restringir el uso o divulgacion acerca de mi salud en caso de situaciones de emergencia, o para llevar a cabo un tratamiento, pagos, o una operacion; recomendada por The Arc. - The Arc no esta obligada a aceptar ninguna restriccion en el uso o divulgacion que yo solicite. Cliente: Guardian* Nota: Firmando como guardian, certifico que yo soy el guardian legal del cliente, designado por la Corte. Si hay un guardian legal, no es necesario mas firmas. Promotor* Como promotor, por favor marque el espacio que refleje su relacion con el cliente. Mi relacion es: Padres Esposo(a) Hijo(a) adulto Hermano(a) adulto Otro: Nota: Firmando como promotor del cliente, verifico que estoy actuando en su nombre en relacion a este Aviso y a las especificas practicas privadas anotadas en el.

5 * Una de estas firmas es requerida por el grupo de tratamiento, si el individuo no tiene la capacidad de endender este Aviso.

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