Imagine!

 

Notice of Privacy Practices
 
 

 

 

 

  

Effective: April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice will tell you how we gather, use and disclose protected health information about you (your dependent). Protected health information means any health information about you (your dependent) that identifies you (your dependent) or for which there is a reasonable basis to believe that the information can be used to identify you (your dependent).

This notice will also tell you about your rights and our duties with respect to you (your dependent). It will also tell you how to complain to us if you believe that we have violated your privacy rights.

For purposes of this notice health care includes, but is not limited to "preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body." IMAGINE! has determined that all confidential, identifiable information that is obtained about you (your dependent) will be designated as "protected health information".

IMAGINE! gathers protected health information about you (your dependent) for a variety of purposes.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU (YOUR DEPENDENT)

Determination of Eligibility for Services for children 0 through 2 years of age, eligibility is generally not determined by IMAGINE! staff, but rather by other entities such as hospitals, health departments, and Child Find. Information from these entities is forwarded, with written parental authorization to Service Coordinators employed by IMAGINE! to assist the child and family locate appropriate services. The only determination of eligibility made directly by IMAGINE! Service Coordinators would be when a child is referred for services who does not have assessed developmental delays, but whose parent(s) have been determined to have a developmental disability.

For applicants age 3 years and over, eligibility is determined generally by the IMAGINE! Intake/Transition Case Manager. Protected health care information is sometimes shared with the IMAGINE! Case Management Director if the eligibility of the applicant is questionable. If neither the Intake Case Manager nor the Case Management Director can make a determination of eligibility, the matter is referred to the Referral and Placement Committee. The Committee is composed of IMAGINE! staff and volunteer representatives of external organizations such as adult residential and vocational providers and the Association for Community Living. Committee members receive a summary of protected health information in writing. The applicant and/or personal representative is invited verbally and in writing to attend the meeting and to share information that they believe to be relevant to the determination of eligibility.

When an applicant requires additional psychological testing to determine eligibility for services, protected health information is shared with the psychologist with whom IMAGINE! contracts to do such testing.

Periodically a referral is made from the Juvenile Court in Boulder or Broomfield counties to determinate if a child appearing in that Court is developmentally disabled. If such a determination is made, different sentencing options are available. Protected health information obtained by IMAGINE! is not shared with the Court except by subpoena, but the Court receives a written determination of eligibility based on that information.

To Obtain Treatment (Services and Supports)

IMAGINE! may use protected health information about you to provide, obtain, coordinate and manage the services, supports and other health care you receive from us, or other providers with which we contract. This information may be disclosed to doctors, nurses, dentists, psychologists, social workers, mental health professionals, case managers or service coordinators, direct service staff at IMAGINE! and IMAGINE! staff charged with quality assurance monitoring, administrative and direct care staff of other service providers with whom IMAGINE! contracts, community agencies and providers that provide services to people with developmental disabilities outside of the developmental disabilities service system, and State agencies that have audit and quality assurance responsibilities.

In general, information is shared for the purpose of obtaining services, supports and other health care services and coordinating such services as they are outlined in the Individual Family Service Plan (IFSP) or the Individual Plan (IP). For a child 0-2 years of age, for example, a family may choose to receive services from a private speech therapist in the community, rather than through a system based service provider like Dayspring. IMAGINE! will contract with the therapist on behalf of the child/family. An adult may need assistance from Vocational Rehabilitation as well as a system based vocational provider to obtain and retain employment. An adult may choose to have comprehensive services (residential services) provided by an agency other than the IMAGINE!. provider. IMAGINE! will contract for services from that provider on behalf of the adult. Protected health information will be shared with those agencies to enable them to provide appropriate and needed services as outlined in the IP. A nurse with a residential provider may share protected health information to obtain medical services for the individual.

For Payment

We may use and disclose health information about you so that we can be paid for services we provide for you or purchase on your behalf. This may include billing third party payers such as Developmental Disabilities Services, Medicaid or your insurance company. IMAGINE! may bill the insurance company of a child 0-2 years of age for additional services provided beyond what is offered through Day Spring. Developmental Disabilities Services (Colorado State agency which provides funding for services for people with developmental disabilities) would be billed for all services provided to adults in the developmental disabilities services system.

For Health Care Operations

We may use and disclose health information about you (your dependent) for our own operations. This information may be used to monitor the performance of staff providing services, to determine internally the quality of services being provided, to train staff and/or volunteers or to prepare for external audits and reviews.

For Planning Purposes

Each individual enrolled in services through IMAGINE! has a plan of services/supports developed. This Plan is developed with input from a variety of individuals which includes the parent of a minor child, the adult with developmental disabilities and the guardian or other personal representative of the adult with developmental disabilities, as needed. Private health information is shared at the meetings to develop these plans.

Referral and Placement Committee

See Determination of Eligibility for Services section on p.1 of this notice. All members of this Committee sign a confidentiality agreement prior to serving on the Committee.

Human Rights Committee

By Colorado law, Section 27-10.5-105 C.R.S. each community centered board (IMAGINE!) must establish a Human Rights Committee (HRC) as a third party mechanism to safeguard the rights of individuals receiving services. Most reviews involve adults receiving services, but children receiving services in the Children's Extensive Waiver are also covered. The HRC reviews all use of psychotropic medications for adults in Comprehensive Services and nursing homes, use of emergency or safety control procedures (generally some form of physical intervention); and a suspension of rights or restrictive procedure that are part of a behavior program for an individual in services. The HRC also reviews all investigations of abuse, neglect, mistreatment or exploitation and may institute their own investigation as warranted.

Members of the HRC are volunteers and may not be staff of any service provider in Boulder or Broomfield counties. Committee members sign a confidentiality agreement prior to serving on the Committee. Protected health information is shared during meetings of the HRC. Individuals being reviewed and/or their personal representative are invited to attend the meeting and provide their opinion about the issue being reviewed.

IMAGINE! Allocation Committee

The Allocation Committee is composed of senior administrative staff from IMAGINE!. Protected health information is used to inform the Committee of the utilization status of the Adult Supported Living Program and the Children's Extensive Waiver Program (CES). The Allocation Committee approves initial plans and hears requests to allocate additional funds for individuals in these services.

The Allocation Committee also hears requests from comprehensive service providers (residential and day) to change funding levels for individuals in their services. Protected health information is used in this process from IMAGINE! direct service providers and contractors.

Treatment and Service Alternatives

We may use and disclose health information about you to contact you about alternative treatment and service options that might be of interest to you. We may do this by mail, or phone, or in face-to-face contact. We will not provide such information to alternative treatment or service providers without your express written authorization.

Disclosures to Family and Others

We may disclose to a parent/guardian, personal representative, family member, or any other person identified by you, health information about you (your dependent) that is directly related to their involvement with the services and supports you (your dependent) receive. We may also use that information to notify such persons about your location, general condition or death. If there are individuals in your life ( or of your dependent's life) that you do not wish to have this information, please notify your (your dependent's) service coordinator or case manager. If you are not certain who the service coordinator or case manager is, please contact Marianne Nick, IMAGINE! Case Management Director at 1400 Dixon St., Lafayette, CO 80026. 303-926-6425 or by email.

Disaster Relief

We may use or disclose health information about you (your dependent) to a public or private entity authorized by law to assist in disaster relief efforts. This will be done in coordination with those entities to ensure that a parent/guardian, other personal representative or any other person designated by you are notified of your location, general condition or death in the event of a disaster.

Required by Law

We may use or disclose health information about you when we are required to do so by law.

Public Health Activities

We may disclose health information about you for public health activities and purposes. This includes reporting health information to a public health authority that is authorized by law to collect or receive information for purposes and preventing and controlling disease. This would also include reporting for purposes related to the quality, safety or effectiveness of a United States Food and Drug Administration regulated product or activity. Examples of the latter might involve a serious adverse reaction to medication or a food supplement, or a safety issue with some product.

Victims of Abuse, Neglect, Mistreatment or Exploitation

By Colorado law, and by State and Imagine! regulation, IMAGINE! employees and contractors are obligated to report suspected abuse, neglect, mistreatment or exploitation of a minor child to the Boulder County or Broomfield County Dept. of Human Services and/or local law enforcement agencies. IMAGINE! employees and contractors are encouraged by State statute and required by IMAGINE! regulation to report suspected abuse, neglect, mistreatment or exploitation of an at-risk-adult (all adults with developmental disabilities are determined to be at-risk adults) to the Adult Protection unit of the Boulder or Broomfield Dept. of Human Services, and/or to local law enforcement agencies. As part of this reporting process we may share health information with these agencies to the extent that this disclosure is: (a) required by law; (b) agreed to by you or your personal representative; (c) authorized by law and we believe that the disclosure is necessary to prevent serious harm to you or to other potential victims, and we are informed by a law enforcement or other public official that immediate intervention is dependent upon this disclosure of the health information.

Health Oversight Activities

We may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure, or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs and entities subject to government regulation. Some of the most common oversight agencies to receive this information are Developmental Disabilities Services, Children's Health and Rehabilitation Services, Rehabilitation Accreditation Commission, Inc., Colorado Dept. of Health, county Department of Human Services for foster care licensing., local fire departments.

Judicial and Administrative Proceedings

We may disclose health information about you in the course of any judicial or administrative proceeding in response to an order from the Court or administrative tribunal. We may also disclose health information about you in response to a subpoena, discovery request or other legal process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed. The information disclosed will be only that specifically asked for in the subpoena, discovery request, order of the Court or of the administrative tribunal.

Disclosure for Law Enforcement Purposes

We may disclose health information about you to a law enforcement official for law enforcement purposes:

  1. As required by law;
  2. In response to a court, grand jury or administrative order of subpoena;
  3. To identify as suspect or locate a suspect, fugitive, material witness or missing person;
  4. About an actual or suspected victim or a crime and that person agrees to the disclosure. If we are unable to obtain that person's agreement, in limited circumstances the information may still be disclosed.
  5. To alert law enforcement to a death if we suspect that the death may have been caused by a criminal act;
  6. About crimes that occur in our programs;
  7. To report a crime in emergency circumstances

Coroners or Medical Examiners

We may disclose health information about you to a coroner or medical examiner for purposes such a identifying a deceased person and determining cause of death.

Funeral Directors

We may disclose health information about you to funeral directors as necessary for them to carry out their duties.

Organ, Eye or Tissue Donation

We may disclose health information about you (your dependent) to organ procurement organizations or other entities engaged in the procurement, banking or transplantation or organs, eyes or tissues. This disclosure will be made only if you have left written instructions stating that you wish to be an organ donor, or if you are incapacitated, organ donation is agreed to by your personal representative.

Research

Under some circumstances we may disclose health information about you (your dependent) for research. Before we disclose health information for research, the research will have been approved through an approval process, which includes the Human Rights Committee, which evaluates the need for the research against your needs for the privacy of your health information. We may, however, disclose health information about you (your dependent) to a person who is preparing a research proposal. No health information will leave IMAGINE! during this person's review of the information.

Research participants served by IMAGINE!, or their personal representatives, must provide written informed consent prior to becoming a part of a research project. By Colorado regulation, informed consent may be provided only after consultation with the Interdisciplinary Team for the individual and with a developmental disabilities professional not associated with IMAGINE!

To Avert Serious Threat to Health or Safety

We may use of disclose health information about you (your dependent) if we believe that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health and safety of a person or the public. We may also release information about you (your dependent) if we believe the disclosure to be necessary for law enforcement authorities to identify or apprehend an individual who admitted participating in a violent crime or who is an escapee from a correctional institution or from lawful custody.

Inmates: Persons in Custody

We may disclose health information about you (or your dependent) to a correctional institution or law enforcement official having custody of you (your dependent). This disclosure will be made if the it is necessary to: (a) to provide health care to you; (b) for the health and safety of others, or, (c) the safety, security or good order of the correctional institution.

Marketing Communication

We may use health information to inform you about the variety of services and supports that are available to you (your dependent) in Boulder and Broomfield counties, and to give you information about the providers of those services, supports and goods. We may communicate this information to you face-to-face, in a phone conversation, by fax or e-mail or through regular mail, such as an IMAGINE! newsletter. We will not disclose health information to providers, so that they may promote their services or product to you, without your written authorization.

Fundraising

We may use information about you to raise funds for IMAGINE! directly or through the IMAGINE! Foundation. We would use only name, address and phone number. If you do not want IMAGINE! or its Foundation to contact you for fundraising purposes, please contact Heather Sabo at 303-926-6470 or by email.

How We Will Contact You

Unless you tell us otherwise in writing, we may contact you by telephone, fax or e-mail at home or at work. In either place we may leave messages. If you want us to communicate with you only in a certain way or at a certain place, please contact your (your dependent's) Case Manager or Marianne Nick, Case Management Director at 303-926-6425 or by email.

YOUR RIGHTS WITH RESPECT TO HEALTH INFORMATION ABOUT YOU

You have the following rights with respect to health information that we maintain about you.

Right to Request Restrictions

You have the right to request that we restrict the uses or disclosures of health information about you to carry out treatment, payment or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or (b)to public or private entities for disaster relief purposes. For example, you could ask us not to disclose health information to a brother, sister, or even a parent unless that parent is your legal guardian.

You may request a restriction at any time. To do so contact Marianne Nick, IMAGINE! Case Management Director at 303-926-6425. A phone request will be recorded and honored, but it would be most helpful for documentation and continuity purposes to also receive your request for a restriction in writing. Written requests should be sent to Marianne Nick, IMAGINE! Case Management Director, 1400 Dixon St., Lafayette, CO 80026 or via e-mail.

Your request, whether verbal or written, should contain the following information: (a) what information you want to limit; (b) whether you want to limit use, disclosure or both; and, (c) to which persons or organizations you want the limits to apply.

We are not required to agree to any requested restrictions. However, if we do agree, we will follow the restriction(s) unless the information is needed to obtain or provide emergency treatment. If we agree to a restriction, either you or we may terminate the restriction at a later time.

Right to Receive Confidential Communication

You have the right to request that we communicate information about you to you in a certain way or at a certain location. For example, you can ask that we contact you only by mail or by phone, and only at home. We will not require you to tell us why you are making this request.

If you want to request confidential information, you must do so in writing to Marianne Nick at the previously listed mail and e-mail addresses. You need to include information about how and where you are to be contacted. If it will be difficult to contact you at your preferred location, please try to include a secondary location or means for contact. For example, if your preferred location for contact is your work phone, but you are seldom at your desk, providing a cell phone or pager number would be helpful.

Right to Inspect and Copy

You have the right to inspect and obtain a copy of health information about you. You will be provided with one copy of this information at no charge. Any additional copies will be provided at a reasonable fee per copied page, plus mailing costs if it is requested that the information be mailed.

To inspect or copy health information about you, you must submit your request in writing to Marianne Nick at the previously listed mail and e-mail addresses. Your request should specifically state what health information you want to inspect or copy.

We will act on your request within 30 calendar days of the receipt of you r request. If we grant your request in whole or in part, we will inform you of our acceptance and of the request and provide access and copying. We will require that a staff person from IMAGINE! be present while you inspect or copy health information.

We may deny your request to inspect and copy health information if the health information is:

  • Psychotherapy notes
  • Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding;
  • Being requested to be reviewed or copied by someone other than yourself, if such information is protected by more stringent disclosure statutes such as alcohol or substance abuse information or HIV status.

If we deny your request, we will inform you of the basis for the denial, how you may have the denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by IMAGINE! who was not directly involved in the denial. IMAGINE! will comply with the outcome of that review.

Right to Amend

You have the right to ask to amend health information about you. You have this right so long as the health information is maintained by IMAGINE!

To request an amendment, you must submit a request in writing to Marianne Nick at the previously listed mail and e-mail addresses. Your request must state what information you wish to amend and provide a reason(s) that supports the amendment.

We will act on your request within no later than 60 calendar days from receipt of your request. If we grant your request, in whole or in part, we will inform you of our acceptance.

If we grant the request, in whole or in part, we will seek your identification of, and agreement to share the amendment with relevant other persons. We will also make the appropriate amendment to the health information by appending the information.

We may deny your request to amend health information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. We may also deny your request to amend the specified health information if we determine that the information:

  • Was not created by IMAGINE! staff unless the person or entity that created the information is no longer available to act on the requested amendment;
  • Is not part of the health information maintained by us;
  • Would not be available for you to inspect or copy; or
  • Is accurate and complete.

If we deny your request, we will inform you of the basis for the denial. You will then have the right to submit a statement of disagreement with our denial. We may prepare a rebuttal to that statement. . Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any will then be appended to the health information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of the information.

If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosures of the information.

You also have the right to complain about our denial of your request. You may do this by putting your complaint in writing to: Leslie Brossman, Director of Quality Assurance, IMAGINE!, 1400 Dixon St., Lafayette, CO 80026 or by email.

Right to an Accounting of Disclosures

You have the right to receive an accounting of disclosures of health information about you. The accounting may be for up to six (6) years prior to the date on which you requested the accounting, but may not be for disclosures made prior to April 14, 2003.

Certain types of disclosures are not included in such an accounting:

  • Disclosures to carry out treatment, payment and health care operations;
  • Disclosures made to you, your guardian or other personal representative;
  • Disclosures that are incidental to another use or disclosure;
  • Disclosures that you have authorized;
  • Disclosures to persons involved with your care;
  • Disclosures for disaster relief purposes;
  • Disclosures to correctional institutions or to law enforcement officials;
  • Disclosures that are part of a limited data set (all identifying information has been removed) for purposes of research, public health, or health care operations

Under certain circumstances, and as requested by the law enforcement officials or health oversight agencies involved, your right to an accounting of disclosure of information to these entities may be suspended. Should you request an accounting during the time that your right is suspended the accounting would not include disclosures to a law enforcement official or to a health oversight agency.

To request an accounting of disclosures, you must submit your request in writing to Marianne Nick at the previously listed mail and e-mail addresses. Your request must state the time period for which you want the disclosures. That period may be no longer than 6 years prior to the date of receipt of your request, and may not include dates before April 14, 2003.

We will act on your request within 60 calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or provide a written statement of when we will provide the accounting and why a delay is necessary.

There will be no charge for the first accounting we provide to you in any 12 month period. For additional accountings we may charge you the cost of providing the list. If there is to be a charge we will inform you of what the cost will be so that you may withdraw or modify your request to avoid or reduce the fee.

Right to a Copy of This Notice

You have the right to obtain a paper copy of this notice and may request such a copy at any time.

A paper copy will be sent to all individuals enrolled in services or on waiting lists to be enrolled in services through IMAGINE! on April 14, 2003.

A paper copy of this notice will be provided to each new applicant during the intake and eligibility determination process at IMAGINE!

A new paper copy of this notice will be provided yearly at Individual Plan (IP) or Individual Family Service Plan (IFSP) meetings only if provisions of this notice have been changed.

You may also obtain a copy of our Notice of Privacy Practices over the Internet at our web site at www.imaginecolorado.org.

A copy of this notice will also be posted at each program site operated directly by IMAGINE!

To obtain a paper copy of this notice contact Marianne Nick at the previously listed mail and e-mail addresses or at 303-926-6425.

We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

Our Right to change Notice of Privacy

We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the notice's provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.

A paper copy of this changed notice will be provided at the yearly IP or IFSP meetings for individuals enrolled in services through IMAGINE! and by mail to individuals on waiting lists.

A paper copy of the changed notice will also be provided to new applicants at the time of intake and eligibility determination.

A copy of the changed Notice of Privacy will also be posted on the IMAGINE! web site: www.imaginecolorado.org.

The changed Privacy Notice will also be posted at all program sites operated directly by IMAGINE! by the date the changes become effective.

Complaints

You may complain to IMAGINE! and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with IMAGINE!, contact Leslie Brossman, Director of Quality Assurance, IMAGINE!, 1400 Dixon St., Lafayette, CO 80026 or e-mail her at lesbros@imaginecolorado.org. Her phone is 303-926-6401. All complaints must be submitted in writing.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint to the Secretary in care of: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington D.C. 20201.

You will not be retaliated against for filing a complaint.

Questions and Information

If you have any questions, or want more information concerning this Notice of Privacy Practices, please contact Marianne Nick, Case Management Director, IMAGINE! 1400 Dixon Street, Lafayette, CO 80026 or e-mail her. Her phone is 303-926-6425.

This is to acknowledge my receipt of Imagine!'s Notice of Privacy Practices (effective date 4/14/03).

Date of Individual's or Personal Representative's Signature                                                              

 

Signature of Individual or Representative                                                                



Individual's Name                                                                                



Individual's Address                                                                   

 

Name of Personal Representative or Legal Guardian


Description of Legal Guardian's/Personal Representative's Authority to act for the Individual (If applicable)                          

Please return this form before April 14, 2003 to:
Marianne Nick , Case Management Director/Privacy Officer
Imagine!
1400 Dixon Street
Lafayette CO 80026

 

Dear Consumers, Parents and Personal Representatives:

The federal government has made some new rules regarding the privacy of what is termed "protected health information." IMAGINE! has determined this to be any confidential information that we have acquired about you or your family member. IMAGINE! must tell you how it uses this protected health information" and when, how and under what circumstances it discloses this information to other parties. That information is contained in the Notice of Privacy Practices that accompanies this letter. Unfortunately, the document is long and sometimes difficult to understand. Please feel free to contact us about its contents at any time.

Accompanying this letter and the document is a form that states that you have received the Notice of Privacy Practices. We would appreciate having you sign the form and return it to us in the enclosed envelope as soon as possible. Signing the form does not mean that you agree with what is in the Notice, only that you have received it.

Thank you in advance for your cooperation.

Sincerely,

 

MARIANNE NICK
Case Management Director/Privacy Officer
IMAGINE!
1400 Dixon St.
Lafayette, CO 80026
303-926-6425
email.