This notice is effective as of April 14, 2003. If you have any questions about this notice, please contact the Privacy Officer at Ontario ARC, 585-394-7500 or write to 3071 County Complex Drive, Canandaigua, NY 14424.

At Ontario ARC, 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 to you.

1. Who will follow this notice:

All people who work for Ontario ARC in our programs and services, and in our administrative offices will follow this notice. This includes employees, persons Ontario ARC contracts with (contractors) who are authorized to enter information in your clinical record or need to review your record to provide services to you, and volunteers that Ontario ARC allows to assist you.

2. What information is protected:

• Maintain the privacy of your information.

• Give you this notice of our legal duties and practices concerning the health information we have about you.
• Follow the rules in this notice. Ontario ARC will use or share information about you only with your permission except for the reasons explained in this notice. We will inform you if we make changes to our privacy practices in the future.

• Treatment: Ontario ARC is a health and human services organization that excels in providing the highest quality programs and services to children and adults with disabilities, to their families and to the Finger Lakes community. In order to achieve this, Ontario ARC will use your health information to carry out your outlined services and treatment plan. We may disclose health information to doctors, nurses, psychologists, social workers and other Ontario ARC personnel, volunteers or interns who are involved in providing you care. For example, involved staff may discuss your health information to develop and carry out your individualized service plan. We may need to disclose your health information to your service coordinator and other providers outside of Ontario ARC who are responsible for providing you with the services identified in your service plan or to obtain new services for you.

• Payment: Ontario ARC will use your health/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 billing company with information about the services you received at our facility, or through one of our programs so they will pay us for the services. In addition, we may disclose your health information to receive prior approval for payment of services you may need.

• Health Care Operations: Ontario ARC will use health information for administrative operations. These uses and disclosures are necessary to operate Ontario ARC programs and to make sure all consumers receive appropriate, quality care. For example, we may use health 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 share your health information with Ontario ARC staff to resolve complaints or objections to your services. We may also disclose health information to our business associates who need access to the information to perform administrative or professional services on our behalf.

• Information Provided to You: Ontario ARC may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or services at one of our programs.

• Notification and Communication with Family: Ontario ARC may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our staff members will use their best judgment in communication with your family and others.

• For Public Health Reasons: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing and controlling disease, reporting disease or infection exposure; injury or disability; reporting abuse or neglect; and reporting domestic violence.
• Health Oversight Activities: We may disclose your health information to agencies for audits, investigations, surveys and inspections, licensure and other proceedings. These activities are necessary for government(s) to monitor the health care system, government programs, and compliance with civil rights laws.

• Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding. If you are involved in a court or administrative proceeding, we will disclose health information if the judge or presiding officer orders us to share the information.

• Law Enforcement Purposes: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, witness or victim regarding a crime, a death, any criminal conduct at our facility, a missing person, complying with a court order or subpoena and for any other law enforcement purpose.

• Public Safety: We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to your health and safety or someone else’s.

• Public Relations/Fund-Raising/Grants: Ontario ARC may contact you to give you information about other treatments or health-related benefits and services that may be of interest to you. Ontario ARC may contact you to participate in fund-raising activities for our organization. We may use health information in summary format to describe the scope of agency services for public relations, fund-raising and/or grant applications. For example, a grant application may ask for the organization to describe the nature of individuals served by a specific Ontario ARC program. Such information would describe the general population served and not disclose individual information of a person. Any need to disclose individualized information for public relations, fund-raising or grant purposes would not be disclosed without your specific authorization.

• For all other types of uses and disclosures not described in this Notice, Ontario ARC will use or disclose health information only with a written authorization signed by you or an authorized personal representative 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. If you cannot give permission due to an emergency, Ontario ARC may release health information in your best interest. We must tell you as soon as possible after releasing the information. This notification will be made in writing. You may revoke your authorization at any time. If you revoke your authorization in writing, we will no longer use or disclose your health information for the reasons stated in your authorization. We cannot, however, take back disclosures we made before you revoked and we must retain health information that indicates the services we have provided to you.

• You have the right to review, receive copies and explanations of your health information. This includes information in your chart such as treatment plans and case notes, but excludes such information as incident reports and investigations, and any information compiled for use in court or administration proceedings. Your request to review your information should be put in writing. We will respond to your request in 10 days. If we deny your request, you will receive an explanation of the denial in writing.

• You have the right to ask Ontario ARC to change or amend your health 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 Ontario ARC or if after reviewing your request, we believe that the record is accurate and complete. If we approve the request for amendment, we will amend the health information and inform you of that action and tell others that need to know about the amendment in the Protected Health Information (PHI).

• You have the right to request a list of the disclosures Ontario ARC has made of your health information. We will not, however, keep or provide you with a list of certain disclosures, for example, disclosures made for treatment, payment and health care operations, or disclosures made to you or made to others with your permission. The list of disclosures will also not include disclosures made for required governmental functions, or disclosures made before April 14, 2003. We will respond to your written request for such an accounting within 30 days of receiving it.

• You have the right to ask that we limit how we disclose or use your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

• You have the right to receive a paper copy of this notice.

• If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, you may contact the Privacy Officer at 585-394-7500.

• You may file a complaint with the Ontario ARC Privacy Officer at 3071 County Complex Drive, Canandaigua, NY 14424 or 585-394-7500. If the situation is not rectified in an appropriate manner, you may contact the Secretary of Department of Health and Human Services. You may call them at 877-696-6775 or write to them at 200 Independence Avenue, S.W., Washington, D.C. 20201.
• You may file a grievance with the Office of Civil Rights by calling 866-OCR-PRIV or 866-627-7748, or 886-788-4989 (TTY).