Corporate Office | 4902 Eisenhower Boulevard, suite 315, Tampa, Fl. 33634,

Tampa (813) 295-8383 | Tallahassee (850) 901-0222

Behavioral Health Services Supports Designed to Strengthen the Family Unit

Client RIGHTS

Client Right and Responsibilities

Your Rights:

· To be treated with courtesy and respect, with appreciation of your individual dignity, protection of privacy and maintain your information confidentially.

· To receive treatment free from abuse, financial or other exploitation, retaliation, humiliation, and neglect.

· To receive a prompt and reasonable response to questions and requests

· To know who is providing services, his or her qualifications, and who is responsible for your care

· To participate in the development and review of treatment/service and discharge planning

· To know what client support services are available, including whether an interpreter is available if you do not speak English, or are Deaf or Hard of Hearing

· To know what rules and regulations apply to your conduct

· To be given information regarding the reason for admission, diagnosis, planned course of treatment, alternatives, risks, prognosis and composition of the treatment team.

· To consent to or refuse any treatment, except as otherwise provided by law.

o Consent can be taken back, either verbally or in writing by you, your guardian, or guardian advocate

· To be given full information regarding fees for services and available financial resources for your care prior to treatment.

· Receive a copy of an understandable itemized bill and, if requested, to have the charges explained.

· To have access to care regardless of race, national origin, religion, handicap, or resource of payment.

o If you believe you have been discriminated against in any way, please assist us in our commitment to providing impartial services by contacting the Director of Quality and Credentialing at (813) 290-8560 or email QuailtyManagement@familiesfirstfl.com.

· To give consent or refusal to participate in experimental research

· To express grievances in your dissatisfaction that can include, but is not limited to, services, manner of treatment, outcomes, or experiences.

o To request a copy of FFF’s formal grievance policy and process, please call (813) 290-8560.

o If you wish to file a formal grievance, please contact Quality Management at (813) 290-8560 and they will direct your call.

· To express grievances regarding any violation of your rights, including abuse or neglect, as stated in Florida law. This information is provided during the orientation process and is posted in office reception areas. To express a violation of your rights, clients can also contact the Department of Children and Families at 813-558-5700. To report abuse or neglect, contact the Florida Abuse Hot Line at 1-800-96-ABUSE.

· For youth admitted to FFF’s foster care program, you have a right:

o To the care and custody of your personal belongings.

o To a written inventory of your personal clothing or belongings.

o To receive a minimum allowance, as required by the state, each month.

o To receive an education in the least restrictive, most appropriate environment

Your Responsibilities:

· To provide accurate and complete information to the best of your ability

· To report unexpected changes in your condition.

· To report whether or not you understand a suggested course of action and what is expected of you

· To follow the treatment plan agreed upon by you and your treatment provider

· To keep appointments regularly and to call and cancel any appointments you cannot keep at least 24-hours in advance.

· To act appropriately and safely when there are consequences that result from refusing treatment or not following the treatment provider’s instructions

· To make sure all financial responsibilities are carried out and to communicate as early as possible when you are not able to guarantee payment of any applicable fees.

· To treat all other people within the agency, home, and facility with courtesy and respect

· To refrain from attending appointments when actively infectious or contagious and seek appropriate medical treatment before returning for services

· To follow the facility rules regarding conduct as follows:

o Avoid being violent or threatening to staff, visitors, or other clients. You can be denied services if you become violent or threatening or destroy property which does not belong to you. If you become violent, our staff may use crisis intervention techniques to protect you, themselves, others, and/or property.

o Do not bring unauthorized weapons onto FFF property. If it is discovered that you have an unauthorized weapon, you will be required to leave immediately, and we will inform a law enforcement agency in the event of any threatening behavior.

o Avoid bringing any illegal substance in or around our property. If it is discovered that you have an illegal substance with you, you will be required to leave immediately, and we may inform a law enforcement agency.

o Avoid exposing staff, visitors or other clients to contagious diseases or conditions such as lice, scabies, active tuberculosis, infectious hepatitis, or other contagious diseases. Services can be refused to anyone who has or claims to have, a currently contagious disease or condition until appropriate medical attention has been initiated and the physical condition is no longer contagious.

FFF is a smoke-free environment.
Wear appropriate clothing when in or around our buildings
To permit the Department of Children and Families, and other funding sources to review information regarding your treatment or services if they help pay for your treatment or services provided by FFF

Florida Abuse Hotline

1800-96-ABUSE

Department of Children and Families at

863-578-1733

Your Right to Privacy

(Notice of Privacy Practices)

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.

Families Connect (FC) is required by law to protect certain aspects of your health care information known as Protected Health Information or PHI and to provide you with this Notice of Privacy Practices.

This Notice describes our privacy practices, your legal rights, and lets you know how FC is permitted to:

Use and disclose PHI about you
How you can access and copy that information
How you may request amendment of that information
How you may request restrictions on our use and disclosure of your PHI.

In most situations, we may use this information described in this Notice without your permission, but there are some situations where we may use it only after we obtain your written authorization, if we are required by law to do so.

FC respects your privacy and treats all health care information about our patients with care under strict policies of confidentiality that all of our staff are committed to following at all times.

PLEASE READ THE FOLLOWING DETAILED NOTICE. IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT THE HIPAA PRIVACY OFFICER AT 813-290-8560 ext. 212.

FC is permitted by law to use your PHI:

For treatment: This includes such things as verbal and written information that we obtain about you and use pertaining to your medical condition and treatment provided to you by us and other medical personnel (including doctors and nurses who give orders to allow us to provide treatment to you). It also includes information we give to other healthcare personnel to whom we transfer your care and treatment and includes transfer of PHI via radio or telephone to the hospital or dispatch center as well as providing the hospital, dispatch center, or the hospital with a copy of the written record we create in the course of providing you with treatment and transport.

For payment: This includes any activities we must undertake to get reimbursed for the services we provide to you, including such things as organizing your PHI and submitting bills to insurance companies (either directly or through a third-party billing company), management of billed claims for services rendered, medical necessity determinations and reviews, utilization review, and collection of outstanding accounts. Upon request, you can restrict disclosure of PHI for services paid out of pocket.

For health care operations: This includes quality assurance and improvement activities, licensing and training programs to ensure that our personnel meet our standards of care and follow established policies and procedures, obtaining legal and financial services, conducting business planning, processing grievances and complaints, audit functions, including fraud and abuse detection and compliance, creating reports that do not individually identify you for data collection purposes.

FC may also contact you:

To remind you about appointments and give you information about treatment alternatives or other health- related benefits and services that may be of interest to you.

Use and disclosure that does not require FC to have an authorization:

FC is permitted to use PHI without your written authorization, or opportunity to object in certain situations, including:

· For FC’s use in treating you or in obtaining payment for services provided to you or in other health care operations;

· For the treatment activities of another health care provider;

· To another health care provider or entity for the payment activities of the provider or entity that receives the information (such as your hospital or insurance company);

· To another health care provider (such as the hospital to which you are transported or First Responder Agencies) for the health care operation activities of the covered entity that receives the information as long as the covered entity receiving the information has or has had a relationship with you and the PHI pertains to that relation;

· For health care fraud and abuse detection or for activities related to compliance with the law;

· To a family member, other relative, or close personal friend or other individual involved in your care or payment of care if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family, relatives or friends if we infer from the circumstances that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when your spouse has called the ambulance for you. In situations where you are not capable of objecting (because you are not present or due to your incapacity or medical emergency), we may in our professional judgment, determine that a disclosure to your family member, relative, or friend is in your best interest. In that situation, we will disclose only health information relevant to that person’s involvement in your care. For example, we may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts;

· To a public health authority in certain situations (such as reporting a birth, death or disease as required by law, as part of a public health investigation, to report child or adult abuse or neglect or domestic violence, to report adverse events such as product defects, or to notify a person about exposure to a possible communicable disease as required by law;

· For health oversight activities including audits or government investigations, inspections disciplinary proceedings and other administrative or judicial actions undertaken by the government (or their contractors) by law to oversee the health care system;

· For judicial and administrative proceedings as required by a court or administrative order;

· For law enforcement activities in limited situations, such as when there is a warrant for the request, when the information is needed to locate a suspect or to stop a crime;

· For military, national defense and security and other special government functions;

· To avert a serious threat to the health and safety of a person or the public at large;

· For workers’ compensation purposes, and in compliance with workers’ compensation laws;

· To coroners, medical examiners and funeral directors for identifying a deceased person, determining cause of death, or carrying on their duties as authorized by law;

· For research projects, but this will be subject to strict oversight and approvals. Health information will be released only when there is a minimal risk to your privacy and adequate safeguards are in place in accordance with the law;

· If you are an organ donor, we may release health information to organizations that handle organ procurements or organs, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ donation and transplantation;

· To the food and drug administration(FDA) relating to problems with food, supplements and products;

· We may use or disclose health information about you in a way that does not personally identify or reveal who you are;

· To the Department of Corrections should you be an inmate of a correctional institution. We may disclose to the institution or agents thereof, health information necessary for your health and the safety of other individuals;

Any other use or disclosure of PHI, other than those listed above, including most uses and disclosure of psychotherapy notes, uses and disclosures for marketing purposes and disclosure that constitutes a sale of PHI will only be made with your written authorization, (the authorization must specifically identify the information we seek to use or disclose, as well as when and how we seek to use or disclose it.) You may revoke your authorization at any time, in writing except to the extent that we have already used or disclosed medical information based upon that authorization.

Your Health Information Rights:

As a patient, you have a number of rights with respect to the protection of your PHI, including:

The right to access copy or inspect your PHI: This means you may come to our office and inspect and copy most of the medical information that we maintain. We will normally provide you with access to this information within 30 days of your request. We may also charge you a fee to copy any medical information that you have the right to access. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials.

We have forms available for you to request access to your PHI. We will provide a written response if we deny you access and let you know your appeal rights. If you wish to inspect and copy your medical information, you should contact the privacy liaison listed at the end of this Notice.

The right to request amending your PHI: You have the right to ask us to amend written medical information that we may have about you. If errors are found, we will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information, but only in certain circumstances. For example, if we believe the information is correct and no errors exist, your request will be denied. If you wish to request that we amend the medical information that we have about you, you should contact in writing the privacy officer listed at the end of this Notice. You have a right to amend your PHI for as long as we keep it.

The right to request an accounting of our use and disclosure of your PHI: You may request an accounting from us of certain disclosure of your medical information that we have made in the last six years prior to the date of your request. We are not required to give you an accounting of information we have used or disclosed for purpose of treatment, payment, or health care operations, or when we share your health information with our business associates such as our billing company or a medical facility from/to which we have transported you.

We are also not required to give you an accounting of our uses of protected health information for which you have already given us written authorization. If you wish to request an accounting of the medical information about you that we have used or disclosed that is not exempt from the accounting requirement, you should contact the privacy officer listed at the end of this Notice.

The right to request that we restrict the uses and disclosures of your PHI: You have the right to request that we restrict how we use and disclose your medical information that we have about you for treatment, payment or health care operations, or to restrict the information that we have about you for treatment, payment, or health care operations, or to restrict the information that is provided to family, friends, and other individuals involved in your health care. However, if you request a restriction and the information you ask us to restrict is needed to provide you with emergency treatment, then we may use the PHI or disclose the PHI to a health care provider to provide you with emergency treatment. FC is not required to agree to any restrictions you request, but any restrictions agreed to by FC are binding on FC.

Copy of Paper Notice on Request: A copy of this Notice will be posted and made available through the FC Web-site; copies are also readily available at the FC Polk and Tampa offices.

Revision to the Notice: FC reserves the right to change the terms of this Notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain. Any material changes to the Notice will be promptly posted in our facilities and posted to our web site. You can get a copy of the latest version of this Notice by contacting the Privacy Officer identified below.

Your legal Rights and Complaints: You also have the right to complain to us, or the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or to the government. Should you have any questions, comments or complaints you may direct all inquiries to the privacy officer listed at the end of this Notice.

Right to be Notified of Breaches: You have the right to be notified if there is a breach in the unsecured PHI.

Complaints regarding your privacy:

If you have any questions or if you wish to file a complaint or exercise any rights listed in this Notice, please contact:

HIPAA Privacy Officer Liaison

5707 N 22nd St Tampa, FL 33610

813-236-3594

You can also submit a complaint to the United States Department of Health and Human Services. Send to:

Office for Civil Rights

U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
OCR Hotlines-Voice: 1-800-368-1019