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. We are pleased you are a current or potential customer of our agency’s services and to be providing the following information to you as required by federal law. We are required to meet all procedures and standards defined in this notice.  You have a right to a hard copy of this notice.

Your Privacy is Important

GPCS understands your privacy is important. All information we receive about you will be used only to assist you. We will handle this information only as allowed by federal and state law and agency policy.

If at any time you believe your privacy rights have been violated, you may verbally or in writing contact the GPCS Privacy Officer, the State Department of Behavioral Health and Developmental Services Human Rights Advocate, or the Secretary of Health and Human Services. Their names, addresses and phone numbers are listed on the last page of this notice. You will not suffer change in services or retaliation for filing a complaint.

Each time you receive services from us, we will make a record of the visit. Typically, this record contains your assessment, service plan, progress notes, diagnoses, treatment, and plan for future care or treatment.

Your Federally Defined Rights under HIPAA

There are several rights concerning your health information in the medical record that we want you to be aware of:

• You have the right to request access to your medical record to inspect, copy, amend, or correct it. This process will be kept confidential. This right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You may make this request to your Primary Service Provider.
• You have the right to receive at any time an accounting of the agency’s disclosure of your medical record.
• You have the right to request a restriction with regards to the use or disclosure of your medical record. This request will be given serious consideration, and you will be informed promptly whether we will be able to use the restriction and still offer effective services, receive payment, and maintain health care operations. Legally we are not required to abide by any restrictions you request.

Use and Disclosure of Your Information

Upon signing the agency’s Consent for Services, you are allowing us to use and disclose necessary information about you within the agency and with business associates to provide treatment/service, receive payment of provided treatment or service, and conduct our day to day business practices. 

To receive payment of services provided and conduct healthcare operations, your health information may be sent to those companies or groups responsible for payment coverage, and a monthly bill is sent to the Responsible Party identified by you and noted on the financial form. 

In day-to-day business practices, trained staff may access your electronic medical record for billing purposes, to schedule or change appointments, and for electronic filing of documentation. Certain data elements are entered into our computer system that processes most billing, and for state statistical reporting to Virginia Department of Behavioral Health and Developmental Services. As a part of our continuous Quality Improvement efforts to provide the most effective services, your record may be reviewed by professional staff to assure accuracy, completeness, and organization.

If a breach occurs that may have compromised the privacy of your information, we will notify you promptly and make required federal and state notifications.

Enhancing Your Healthcare

Some agency programs provide the following support to enhance your overall health care:

• Appointment reminders by call or letter
• Describing or recommending treatment/service alternatives
• Providing information about health-related benefits and services that may be of interest to you

Specific Circumstances for Disclosure

We are allowed by federal and state law in certain circumstances to disclose specific health information about you without your consent, authorization, or opportunity to agree or object. There may be documentation available to you upon your request listing what information was disclosed, to whom and for what reason.

These specific circumstances are:

• As required by law (ex: Court-ordered warrant)
• Public Health activities (ex: Communicable diseases, Product  Recalls)
• Judicial and Administrative proceedings (ex: Order from a  court or administrative tribunal)
• Law Enforcement purposes (ex: reporting of gunshot wounds; limited information requested about suspects, fugitives, material witnesses, missing persons; witnesses to criminal conduct on premises)
• To avert a serious threat to Health and Safety (ex: in response to a statement made by a person served with intent to harm self or another)
• Children or incapacitated adults who are victims of Abuse, Neglect or Exploitation
• As required during an investigation, audit, licensure, or health oversight entity activities (ex: Department of Health & Human Services, Department of Behavioral Health & Developmental Services, State & Local Human Rights Committees, Inspector General)
• Specialized Government functions
• Military Services (ex: in response to appropriate military command to assure the proper execution of the military mission)
• National Security and Intelligence activities (ex: in relation to protective services to the President of the United States)
• State Department (ex: medical suitability for the purpose of security clearance)
• Historical Research
• Organ Donation Requests (ex: with organ procurement organizations)
• Correctional Facilities (ex: to correctional facility about an inmate)
• Workers Compensation to facilitate processing any payment
• Coroners, Medical Examiners, or Funeral Director for identification of a deceased person or to determine cause of death.

Other Uses and Disclosures of Your Information by Authorization Only

When you request information to be disclosed to another party or yourself, we will respond within federal and state law.

We are required to get your authorization to use or disclose your protected health information for any reason other than treatment/services, payment, or health care operations, and those specific circumstances outlined previously. We use an Authorization to Release Information Form that specifically states what information will be given to whom, for what purpose, and is signed by you or your legal representative. You can revoke the signed authorization at any time by a written statement given to us to that effect.

In addition to the above, specific Federal Regulations (42 CFR, Part 2, Confidentiality of Alcohol  and Drug Abuse Patient Records) provide additional confidentiality safeguards for persons receiving services for substance use disorders. Some of these regulations may prohibit the uses and disclosures outlined in this notice. Sharing substance use information beyond your GPCS substance use providers, if you receive those services, requires your authorization. GPCS believes in an integrated care model within the agency. If you receive substance use services and decline to share that information with other GPCS providers, then you will be referred out for services. If you receive substance use services, have insurance, and decline to share your substance use information with the insurance company, then you will be assessed full fee for services, and your insurance will not be billed nor will they be able to conduct healthcare operations. If you will be receiving substance use services, your Primary Service Provider will explain the safeguards to you at greater length. If at any time you believe your Alcohol and Drug Abuse Patient Record privacy rights have been violated, contact the local United States Attorney’s Office for the Eastern District of Virginia at: 919 East Main Street, Suite 1900, Richmond, VA 23219. Phone: 804-819-5400 or Fax: 804-771-2316.

Access to your Records

If you would like to review or obtain a copy of your records, please request in writing to GPCS, Attention: Medical Records, P.O. Box 189, Goochland, VA 23063 or by fax to 804-556-5403 or by email to gpcsinfo@goochlandva.us. Please note that requests received by this email are not secure. For copies in any format, there is a charge of $0.25 per page. Fees under $15.00 are waived to the consumer.

Destruction of Records

When you are discharged from services, GPCS will retain your record for a period of 10 years from the date of last contact for adult records, 28 years after birth for minor records, or 2 years after the last date of a limited service. After the retention time period has ended, your record will be destroyed in a manner consistent with HIPAA and state guidelines. Record destruction occurs on an annual basis. A notice will be posted on the agency website at www.gpcsb.org when a record destruction is scheduled. You may exercise your right to request access to your record or to transfer copies of your record to another provider at any time before destruction.

Changes to Privacy Practices

GPCS reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law.

You will receive notice of changes either by mailing or discussion with an agency representative or electronically or a combination of the three.

If you would like additional information concerning our Privacy Policy, or the federal and state laws pertaining to privacy, please contact:

Agency Privacy Officer	State Advocate	VA Secretary of Health & Human Resources
Executive Director	Andrea Milhouse	Janet Kelly
Executive Director, Goochland Powhatan Community Services	Department of Behavioral Health & Developmental Services, Office of Human Rights PO Box 1797 Richmond, VA 23218-1797	PO Box 1475 Richmond, VA 23218
PO Box 189, Goochland, VA 23060	1220 Bank St. 4th Floor, Richmond, VA 23218	1111 East Broad Street, 4th Floor, Richmond, VA 23219
Ph:   804-556-5400 Fax: 804-556-5403	Ph:    804-382-5516 Fax:  804-524-0235	Ph:  804-786-7765 Fax: 804-786-3389