The The Arc of Greater Prince William/INSIGHT, Inc. Privacy Officer
	The The Arc of Greater Prince William/INSIGHT, Inc. Individual Services Coordinator
	The Regional Human Rights Advocate
	The United States Secretary of Health and Human Services

Addresses and phone numbers for these contacts are listed at the end of this notice. You will not experience change in your services or retaliation for filing a complaint.

Each time you receive services from The Arc of Greater Prince William/INSIGHT, Inc., the Program Manager/Residential Counselor makes a record of the services provided. Typically, this record contains your assessment, service plan, individual log 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 section of the Individual Record that The Arc of Greater Prince William/INSIGHT, Inc. wants you to be aware of:

	You have the right to request access to your Protected Health Information (PHI) in order to inspect, copy, amend, or correct it. This right is not absolute. In certain situations, such as if access would cause harm, The Arc of Greater Prince William/INSIGHT, Inc. can deny access. You must make this request in writing to your Program Manager or to the The Arc of Greater Prince William/INSIGHT, Inc. Individual Services Coordinator.
	You have the right to receive an accounting of The Arc of Greater Prince William/INSIGHT, Inc.’s disclosure of your Personal Health Information, at any time.
	You have the right to request a restriction with regards to the disclosure of your Protected Health Information. This request will be given serious consideration and you will be informed promptly whether The Arc of Greater Prince William/INSIGHT, Inc. will be able to use the restriction and still provide effective services, receive payment, and maintain health care activities. Legally, The Arc of Greater Prince William/INSIGHT, Inc. is not required to abide by any restrictions you request.
	You have the right to receive information from The Arc of Greater Prince William/INSIGHT, Inc. at the location you specify and through means you prefer (eg. telephone, mail, e-mail).
	You have the right to a paper copy of this notice. This document is also posted in all agency programs.

Use and Disclosure of Your Information:
The Arc of Greater Prince William/INSIGHT, Inc. uses and discloses necessary information about you within the agency and with business associates in order to provide treatment, receive payment for services provided, administrative purposes, to evaluate the quality of care you receive, and to conduct day-to-day business practices. For example:

	In order to provide health/medical services, your Program Manager/Residential Counselor may consult with various medical practitioners within the community (eg. Primary Care Physician, Psychiatrist, Emergency Services staff). During those consultations, Protected Health Information about you may be shared.
	In order to receive payment for services provided, your Protected Health Information may be sent to those companies or groups responsible for payment.
	In day-to-day business practices, trained staff may handle your physical medical record in order to have the record assembled and available for review by your Program Manager/Residential Counselor and to file documentation. Certain information is submitted to your Case Manager at the Community Services Board for submission into their computer system that processes billing and provides statistical reporting to the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS). As part of The Arc of Greater Prince William/INSIGHT, Inc.’s quality assurance efforts, your record may be reviewed by other professional staff to ensure accuracy and completeness.

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

	Appointment reminders by telephone
	Description or recommendation of treatment alternatives
	Provision of information about health-related benefits and services that may be of interest to you.

Specific Circumstances for Disclosure:
The Arc of Greater Prince William/INSIGHT, Inc. is allowed by federal and state law in certain circumstances to disclose specific Protected Health Information about you, without your consent, authorization, or opportunity to agree or disagree. These specific circumstances may include:

	As required by law and limited to the relevant requirements of the law
	For public health activities-to the Health Department to prevent or control disease
	On behalf of children or incapacitated adults who are victims of abuse, neglect, or exploitation-to report as required by law any suspicion of abuse, neglect, or exploitation
	For health oversight activities-review by the Department of Medical Assistance (Medicaid)
	Judicial and administrative proceeding-in response to a court order
	Law enforcement purposes-to report criminal conduct that occurs on The Arc of Greater Prince William/INSIGHT, Inc. property
	Dead persons-to assist coroners and medical examiners to identify a deceased person or to determine cause of death
	For research in conformity with relevant state laws
	To avert a serious threat to health and safety-to yourself or someone else
	Specialized government functions-for protection of the President of the United States
	Worker’s Compensation-to comply with laws related to Worker’s Compensation

A more detailed explanation of all situations allowed by federal and state law is available upon request.

Other Uses and Disclosures of Your Protected Health Information by Authorization Only:
When you request information to be disclosed to another party or to yourself, The Arc of Greater Prince William/INSIGHT, Inc. will respond within federal and state law.

The Arc of Greater Prince William/INSIGHT, Inc. is required to obtain your authorization to use or disclose your Protected Health Information for any reason other than treatment, payment, health care operations, and those specific circumstances outlined previously. The Arc of Greater Prince William/INSIGHT, Inc. uses an Authorization to Release and Obtain Confidential Information form that specifically states what information about you will be given to whom and for what purpose. The form is designed by you or your Legally Authorized Representative. You may revoke the signed authorization at any time, except to the extent that action has been taken in reliance on it, by giving your Program Manager/Residential Counselor a written statement to that effect.

Changes to Privacy Practices:
The Arc of Greater Prince William/INSIGHT, Inc. reserves the right to change any of its privacy policies and related practices at any time and to make the change effective for all health information that The Arc of Greater Prince William/INSIGHT, Inc. maintains, as allowed by federal and state law.

You will receive notice of changes either by mail, discussion with an The Arc of Greater Prince William/INSIGHT, Inc. representative, electronically, or a combination thereof. 

If you would like additional information concerning the privacy policy or the federal or state laws pertaining to privacy, please contact:

The Arc of Greater Prince William/INSIGHT, Inc. Privacy Officer
13505 Hillendale Dr.
Woodbridge, Va. 22193
(703) 670-4800

The Arc of Greater Prince William/INSIGHT, Inc. Individual Services Coordinator
13505 Hillendale Dr.
Woodbridge, Va. 22193
(703) 670-4800

Regional Human Rights Advocate
Northern Virginia Training Center
9901 Braddock Rd.
Fairfax, Va. 22030
(703) 323-2126
1 877-696-6775 (Toll Free)

United States Department of Health and Human Services
Office of the Secretary
200 Independence Avenue, S.W.
Washington, D.C.
(202) 619-0257
1-877-696-6775 (Toll Free)