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Corporate Headquarters
(610) 239-9600
FAX: (610) 239-9195
106 West Main Street
Norristown, PA 19401

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

General Information

Information regarding your health care, including payment for health care, is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d et seq., 45 C.R.F. Parts 160 and 164, and the Confidentiality Law, 42 U.S.C. 290dd-2. Under these laws, Gaudenzia may not say to a person outside Gaudenzia that you are attending the program, nor may Gaudenzia disclose any information identifying you as an alcohol or drug abuser, or disclose any other protected information except as permitted by federal law.

I further understand that the information specified will be disclosed pursuant to this authorization, and that the recipient of the information may disclose the information and it may no longer be protected by the HIPAA privacy law.

Gaudenzia must obtain your written consent before it can disclose information about your payment purposes. For example, Gaudenzia must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before Gaudenzia can share information for treatment purposes or for health care operations. However, federal law permits Gaudenzia to disclose information without your written permission:

1. Pursuant to an agreement with a qualified service organization/business associate;
2. For research or evaluation;
3. To report a crime committed on Gaudenzia premises or against Gaudenzia personnel;
4. To medical personnel in a medical emergency;
5. To appropriate authorities to report suspected child abuse or neglect;
6. As allowed by court order.

For example, Gaudenzia can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care for you, as long as there is a qualified service organization/business associate agreement in place.
Before Gaudenzia can use or disclose any information about your health in a manner that is not described above, it must first obtain your specific written consent allowing it to make the disclosure. You may revoke any such consent in writing.

Your Rights

Under HIPAA, you have the right to request restriction on certain uses and disclosure of your health information. Gaudenzia is not required to agree to any restrictions you may request; however, if it does not agree, then it is bound by that agreement and may not use or disclose any information which you have restricted except, as necessary in a medical emergency.

You have the right to request that we communicate with you by alternative means or an alternative location. Gaudenzia will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA, you also have the right to inspect and copy your own health information maintained by Gaudenzia, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil or administrative proceeding, or in other limited circumstances.

Under HIPAA, you also have the right, with some exceptions, to amend health care information maintained in Gaudenzia records, and to request and receive an accounting of disclosures of your health related information made by Gaudenzia during the six years prior to your request. You also have the right to receive a paper copy of this notice.

Gaudenzia Duties

Gaudenzia is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. Gaudenzia is required to abide by the terms of this notice. Gaudenzia’s reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. Gaudenzia will mail notice of these changes to all covered individuals at the last known address known to Gaudenzia.

Complaints and Reporting Violations

You may file a complaint with Gaudenzia and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated under HIPAA. Complaints made to Gaudenzia shall be in writing to the program director. You will not be retaliated against for filing such a complaint.
Violation(s) of the Confidentiality Law by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.

Contact:
For further information, contact Gaudenzia Privacy officer at 610-239-9600, Ext 231

Effective Date
This notice is effective April 14, 2003.