HIPAA Privacy Practices

Notice of Privacy Practices

EFFECTIVE: June 25, 2024

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.

This notice describes the privacy practices of the Department of Behavioral Health and Developmental Services (DBHDS) including Central Office and each of the psychiatric hospitals and training centers DBHDS operates.  DBHDS is required by law to provide you with this notice telling you about our legal duties and privacy practices with respect to health information.

If you have someone making decisions on your behalf because you are not able to make decisions yourself, we will give a copy of this notice to that person and we will work with that person in all matters relating to uses and disclosures of your health information.  

Summary of Your Rights

You have the right to:

  • Get a copy of your paper or electronic medical record
  • Ask us to amend your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information

Our Uses and Disclosures

We may use and share your information for:

  • Finding someone to make decisions on your behalf
  • Treating you
  • Healthcare Operations
  • The Facility Directory
  • Billing for your services
  • Working with Business Associates
  • Help with public health and safety issues
  • Food and Drug Administration (FDA)
  • Research
  • Decedents
  • Complying with the law
  • Responding to organ and tissue donation requests
  • Working with a medical examiner or funeral director
  • Victims of Abuse and Neglect
  • Addressing workers’ compensation, law enforcement and other government requests
  • Judicial and Administrative proceedings
  • Correctional Institutions and Other Law Enforcement Custodial Situations
  • Student Disclosures (Immunizations)

Explanation of Your Rights

You have certain rights to your health information.  This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
  • We may deny your request in certain circumstances.  If you are denied access to your health information, you may request that the denial be reviewed.  A physician or licensed clinical psychologist not involved with your care will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.  If you are denied access to any portion of your record, you have the right to ask that a psychiatrist, doctor, psychologist or lawyer of your choosing get a copy of wat has been denied to you.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request.  If we are unable to provide the summary to you within 30 days, we are permitted to request an extension in writing of an additional 30 days.  We may charge a reasonable, cost-based fee.

Ask us to correct your paper or electronic medical record

  • You may request an amendment of your medical record in writing, if you think it is incorrect or incomplete.
  • We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communication

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit the information we share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared your information

  • You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

Get a copy of this privacy notice

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
  • Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you believe your privacy rights have been violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 7.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting HIPAA What to Expect | HHS.gov

You will not be retaliated against for filing a complaint

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, tell us.  

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory
  • Provide mental health care

If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes
  • We will never share any substance abuse treatment records without your written permission, except for these instances:
    • To medical personnel to the extent necessary to meet a bona fide medical emergency.
    • To qualified personnel for the purpose of conducting scientific research, management or financial audits, or program evaluations (but individual patients cannot be identified by those personnel in any report or otherwise disclosed). •
    • If authorized by a court order showing good cause ((e.g., need to avert a substantial risk of death or serious bodily harm).
  • Except as authorized by court order, no record may be used to initiate or substantiate any criminal charges against a patient or to conduct any investigation of a patient

How do we typically use or share your health information?

 We may use or share your health information in the following ways without your written permission.

To find someone to make decisions on your behalf  

If you are not capable of making medical decisions, we may disclose your health information in order to identify someone to make those decisions for you (called an “authorized representative” or “AR”).  Before we disclose any information, we must determine that the disclosure is in the best of your interests.  

Treat you

We can use your health information and share it with other professionals who are treating you.

Healthcare Operations

  • We can use and share your health information for running our agency, improving your care, and to contact you when necessary
  • Bill for Services
  • We can use and share your health information to bill and get payment from health plans or other entities.  

Facility Directory

We may include your name, location, and a general description of your medical condition in a facility directory.  This directory will not be shared with anyone outside of the facility unless you give us permission to disclose it.  

This Facility does   __  does not __   maintain a facility directory  

Business Associates

Some of our services are provided through contracts or agreements withother public and private entities and some of these contracts or agreements require that health information be disclosed to the contractor (business associate). 

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as; public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.  

Help with public health and safety issues such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Food and Drug Administration

We may disclose information about you to the FDA as necessary for product recalls, withdrawals, and other problems with a product; to track products; or to report adverse events, product defects, or other problems with products.

Research

We may use or share your information for health research

Decedents

Your protected health information is no longer protected once you have been deceased more than 50 years.  Your information may be disclosed to family members and others who were involved in your care or payment for your care prior to your death, unless doing so is inconsistent with any prior express preferences that are known to us.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Victims of Abuse and Neglect

If we reasonably believe that you are a victim of abuse or neglect, we will disclose health information about you to a government agency authorized by law to receive such information, to the extent that we are required to do so by law.

Address workers’ compensation, law enforcement, and other government requests

  • For workers’ compensation claims
  • For law enforcement purposes or with law enforcement officials
  • For health oversight agencies and activities authorized by law.
  • For special government functions such as military national security and presidential protective services.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order or in response to a subpoena.

Correctional Institutions and Other Law Enforcement Custodial Situations

We may disclose health information to a correctional institution if it is necessary for your care or if the disclosure is required by state or federal laws.

Student Disclosures (Immunizations)

  • We may disclose proof of immunization to a school where State or other law requires the school to have such information prior to admitting the student.  Written authorization is no longer required to permit this disclosure.

 Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We are required to obtain a signed attestation from the requesting party before disclosing PHI related to reproductive care for certain purposes. This attestation will ensure that the requesting party will not use or disclose PHI for a purpose prohibited by the HIPAA Privacy Rule at 45 CFR 164.502(a)(5)(iii).
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

If you have any questions and would like additional information, you may contact:

The Privacy Officer, at: 804-873-4180

If you believe your privacy rights have been violated, you can file a complaint by contacting any of the following people:

  • The Privacy Officer, at:  privacy.org@dbhds.virginia.gov
  • The Human Rights Advocate, at:  804-887-7405 
  • The United States Department of Health and Human Services, at: 1-800-368-0119

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html