One Promise is committed to protecting your health information and to being HIPAA compliant in all of our communication. Our confidentiality is stated below.

One Promise Counseling and Education

Confidential Information Dissemination

1. POLICY:

 It is the policy of One Promise Counseling and Education, and a condition of local, state and federal law to ensure that all verbal and written information of persons served is released in a manner that protects the individual’s right to confidentiality regarding their protected health information. Information may not be released without the individual’s written permission, except as the law permits or requires. One Promise Counseling and Education will make reasonable efforts to limit use, disclosure of, and requests for private health information to the minimum necessary to accomplish the intended purpose.

1. PROCEDURES:

1. Information may be released in written and/or verbal form. The release of information will occur upon receipt of an authorization determined as valid. Validity is determined by the presence of each of the following items:

• The name of the person about whom information is to be released, including social security number.

• The specific content of the information that is to be released.

• The person to whom the information is to be released.

• The signature of the person who is legally authorized to sign the release and the date on which the release is signed.

• The expiration date of the authorization does not exceed one year.

• Information that defines how and when the authorization can be revoked.

• Individuals may inspect, copy, change, or remove their protected health information at any time, depending on staff availability.

• If there is an unauthorized release of information the individual will be asked to report this to the program administrator Craig Lippens at 443-835-2681 and if unsatisfied, they can contact the local behavioral health authority (LBHA). The LBHA for One Promise is the Behavioral Health System of Baltimore (BHSB) and their contact number is 410-637-1900. If the matter remains unresolved after meeting with the BHSB to the satisfaction of the patient, they can contact the State of Maryland Department of Health-Behavioral Health Administration (BHA) at 410-767-6500. If the State BHA cannot resolve the issue the patient can contact the accreditation agency for One Promise, ACHC, Accreditation Council for Health Care Facilities.

1. Requests for Information:

• All requests for information will be in writing.

• Requests for information from an individual’s record will be answered within five days from the date of receipt. If the information cannot be provided within this period, the requester will be informed in writing of the reasons for the delay and the anticipated date the information will be available.

• Requests for records that have been incorporated into One Promise Counseling and Education’s records from outside sources will not be released and the requestor will be encouraged to seek those records from their original source.

1. Release of Sensitive Information:

• Information contained within the individual records may have a serious adverse effect on an individual’s mental or physical health if disclosed to the individual. Such information may contain materials requiring an explanation or interpretation to assist in its acceptance and/or assimilation to avoid an adverse impact on the individual’s health. To minimize the risk of a release of information adversely impacting a person served, the following guidelines will apply:

1. The Clinical Director will review all requests of individuals seeking direct access to their records. Information identified as potentially sensitive will be reviewed by the Clinical Director. This review will occur within one working day of the referral.

1. All materials directly related to behavioral health treatment that includes a diagnosis, assessment, or interpretative data will be reviewed by the Clinical Director.

1. If after the professional review of the record, it is believed that disclosure of the information directly to the individual could have an adverse effect on that individual, arrangements will be made to disclose the information to a professional staff member selected by the individual. The staff member will discuss the information with the individual prior to the release.

1. Should it be determined by the professional staff member that after a careful and conscientious explanation of the information to the individual has been made, and it is the opinion that access to the information could be harmful, physical access will be denied. The justification for making the denial will be fully documented by the staff members and final concurrence will be made by the Clinical Director. The individual will be advised of the denial, the reasons for the denial of the request, and advised of the right to file a grievance, should the individual disagree with the decision.

1. Records may be released in the event of a medical emergency or sudden hospitalization.

1. One Promise Counseling and Education’s legal counsel will be consulted when the release of information involves the following circumstances:

• Any request for records that are to be used in a suit against the organization or in a prosecution against a person served.

• All subpoenas for records that were not accompanied by a written consent signed by the person served.

• All requests for information which indicates a possible liability for the cost of care and services.

1. Information may be released without the consent of persons served under the following conditions:

• For use by any One Promise Counseling and Education employee who has a need for information in the performance of their duties to ensure continuity of care.

• To medical personnel who have a need for the information for the purpose of treating a condition which poses an immediate threat to the health of a person served.

• To public health authorities related to infection with HIV when there is a written request that the information and there is a fine or penalty for failure to comply.

• To a spouse or sexual partner of an individual when it is reasonably believed that the individual will not provide disclosure of information related to infection with HIV when that information is necessary to protect the health of the spouse or sexual partner.

• To recover or collect the costs of medical care from third party health care insurance carriers contracted with by the persons served and required by the health plan to be disclosed.

• To Federal, State, or local government agencies or entities charged under applicable laws with the protection of public health and safety. In such cases, the information may be released with the consent of the individual whose records are being requested, or upon receipt of a written request from the head of the government entity. A request for release under these circumstances may be either a standing written request based on reporting requirements, or a specific written request from the head of a law enforcement agency for a special law enforcement purpose. Standing requests must be updated in writing every year.

• Disclosure because of a court order from a court of competent jurisdiction.

• To the Department of Children and Family Services for the purpose of investigating abuse, neglect, or exploitation.

• To the Medical Examiner, in conjunction with an investigation of a suspicious death.

• To professional review organizations, in accordance with government contracts (Medicare/Medicaid).

• Disclosure of information to a third-party payer in a care cost recovery action will be limited to date of birth; social security number; payment history; and account number, unless the individual provides a written consent designating further information to be released.

1. An accounting record will be maintained on all records released by One Promise Counseling and Education. It will include the date, nature and purpose of each disclosure, the name of the party to whom the disclosure is made. This accounting record will be maintained in the record from which the disclosure was made. In addition, a logbook will be maintained for all release of information for data reporting purposes.

1. Special consent is required to release records that contain information related to drug and alcohol addiction and abuse, and tests for, or infection with human immune virus. Any authorized disclosure from records containing information of this type will be limited to that information which is necessary for the purpose of the disclosure. Because of the special nature of this information, the release must be processed by the Clinical Director to assure compliance with the special regulatory requirements.

1. The following type of communications do not constitute disclosure of information/records:

• Communication of information between any One Promise Counseling and Education employees who have a need for the information in connection with their official duties.

• Communications with law enforcement offices which are directly related to the person served committing or threatening to commit a crime on the organization’s property or against an employee of the organization.

• Communication of information which does not provide an individual’s identifying information.

1. One Promise Counseling and Education will protect the confidentiality of private health care information when transferring data electronically by adherence to the following guidelines:

• All data sets containing individual names transferred on a diskette, e-mail, or any other electronic medium, will be password encrypted.

• The sending and receiving parties prior to transfer of the electronic data will negotiate passwords.

• Passwords will be at lease eight characters in length, contain both letters and numbers, and must not be commonly used words.

• Passwords for encrypted files may not be mailed in the same shipping package as the encrypted file.

1. One Promise Counseling and Education will adhere to the following guidelines when mailing confidential private health information:

• Stamp all envelopes containing records as confidential.

• Clearly indicate a particular office to the address where the envelope is to be delivered.

• Whenever possible, include in the address the name of the staff member authorized to open the envelope.

• All envelopes individually addressed will contain the following statement on the outside of the envelope: “TO BE OPENED BY ADDRESSEE ONLY”.

1. When faxing confidential information, the following guidelines will apply:

• Confidential private health information will only be transmitted by fax when necessary or required by the requestor, and other traditional methods such as confidential mail is not possible to deliver the information.

• All fax cover pages for confidential information will contain the following:

1. The name and program of the person to whom the fax is intended.

1. The name, program, and phone number of the person sending the fax.

1. The statement “Confidential Information” in a large bold font.

1. A statement that clearly identifies the accompanying material as confidential information that reads as follows: “The documents accompanying this facsimile transmission contain confidential information which is legally privileged. The information is intended only for the use of the recipient named above. If you have received this facsimile in error, please immediately notify us by telephone to arrange for return of the documents to us, and that you are hereby notified that and disclosure, copying, distribution or the taking of any action in reliance on the contents of this facsimile information is strictly prohibited.”

• In situations where the information is not being regularly faxed to a common organization and individual, a phone call will be made to the person receiving the fax to verify the fax number and a follow-up call will be made to ensure the receipt of the fax.

• Fax transmissions will be restricted to persons specifically authorized to transmit confidential information.

• Fax machines will not be situated in common public areas.

• Fax number lists will be current, accurate, and regularly checked.

• All transmission records will be checked to detect possible transmission errors and retained for confirmation purposes.

• Upon the receipt of any confidential misdirected fax, the sender will be contacted, and the information will be shredded.

• When the fax machine is unattended at night or on weekends, the print memory will be activated to prevent printing confidential information when staff are not present.

• When a fax server is used in lieu of a machine, password protocols will be in place that will restrict and define user access.

1. Any information released verbally over the phone can only be done after verification of the caller’s identity through taking the phone number and making a call back prior to releasing the information.
2. All telephone calls from outside the organization that request confirmation of an individual being served by One Promise, will be handled by repeating the following statement: “I can neither confirm or deny that the individual in question is receiving services or has ever received services without a written authorization from that individual.”

1. Any One Promise Counseling and Education employee who knowingly and/or willfully violates provisions of this policy and procedures will face administrative disciplinary action that may result in termination of employment.