(V): 937-222-2434 (VP): 937-203-3853 (E): firstname.lastname@example.org
Yourgift can the make the difference.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ CAREFULLY.
This Notice of Privacy Practices is issued in compliance with the federal regulations of the Health
Insurance Portability and Accountability Act and describes how the Deaf Community Resources Center
may use and disclose your protected health information to assess your need for services, to provide
information for those involved in providing services, for reporting purposes, and for other purposes that
are permitted or required by law.
We may use and disclose medical/protected health information for each of the
Treatment means providing, coordinating, or managing health care and related
services. We may disclose medical information about you to other DCRC
personnel who are involved in your treatment and monitoring of your treatment
as required by law. For example, your medical information can be shared with a
supervisor who legally has to sign off on your assessment and treatment plan.
Payment means activities as obtaining reimbursement for services, confirming
coverage, billing or collection activities, and utilization review. For example, we
may need to medical information to the local mental health board or to your
insurance company to receive payment for services.
Health Care Operations include the business aspects of running the agency,
such as conducting quality assessment and improvement activities and customer
services as well as to agency students for review and learning purposes.
We may also create and distribute deidentified health information by removing all
references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
In addition, the agency discloses protected health information to appropriate agents in
the following situations, and in other required instances:
As Required by Law
Military Activity and National Security
Law Enforcement/Criminal Activity
Abuse, Neglect, Exploitation
Emergencies, including emergency transport, such as rescue squads and
medical office and hospital personnel.
Any other uses and disclosures will be made only with your written authorization. You
may revoke such authorization in writing and we are required to honor and abide by that
written request, except to the extent that we have already taken actions relying on your
You have the following rights with respect to protected health information, which you
can exercise by presenting a written request to the Privacy Officer:
health information, including those related to disclosures to family members,
other relatives, close personal friends, or any other person identified by you. We
are, however, not required to agree to a requested restriction. If we do agree to
a restriction, we must abide by it unless you agree in writing to remove it.
protected health information from us by alternative means or at alternative
This notice is effective as of August 1, 2007 and we are required to abide by the terms
of the Notice of Privacy Practices currently in effect. We reserve the right to change the
terms of our Notice of Privacy Practices and to make the new notice provisions effective
for all protected health information that we maintain. We will post and you may request
a written copy of a revised Notice of Privacy Practices from this office.
If you believe your privacy rights have been violated, you may file a written complaint
with the agency or the Department of Health and Human Services. We will not retaliate
against you for filing a complaint.
To file a complaint with Deaf Community Resources Center contact:
Deaf Community Resources Center
Becky Craft, Consumer Rights Officer
Or to file a complaint with the Department of Health and Human Services contact:
The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S. W.
Washington, DC 20201
(202) 619-0257 or 1-877- 696-6775