NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL AND OTHER CONFIDENTIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At Chesterfield Services Inc. (noted as Chesterfield Services), we are committed to maintaining the confidentiality of your medical information, which we refer to as your "personal information." This Notice of Privacy Practices informs you about how we may collect, use and disclose your personal information and your rights regarding that information.

The effective date of this Notice is April 12, 2003. It will remain in effect until we replace it. This Notice pertains to you or your covered dependents.

OUR RESPONSBILITIES TO PROTECT YOUR PERSONAL INFORMATION

Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), Chesterfield Services must take measures to protect the privacy of your personal information. Examples of your personal information include your name, Social Security number, address, telephone number, account number, employment, medical history, health records, claims information, program information, etc.

We protect your personal information in a variety of ways. We see only the minimum amount of confidential information we need to do our jobs. We may share information with other programs or persons if allowed by law or permitted by you. For example, confidential information about your health may be given to and used by healthcare and other providers who take care of you. We may share past, current of future information. We train our employees on our written confidentiality policy and procedures and employees are subject to discipline if they violate them. Our privacy policy and practices apply equally to personal information about current and former clients.

We are required to:

  • Protect the privacy of your personal information;
  • Provide this Notice explaining our duties and privacy practices regarding your personal information;
  • Abide by the terms of this Notice.

  • HOW WE MAY COLLECT YOUR PERSONAL INFORMATION

    We collect your personal information directly from you or from other sources. By signing up for services with us we may obtain your personal information from third parties without your specific authorization. These may include referring agencies, health care providers, other health plans or insurers, and state and federal agencies.

    YOUR RIGHTS REGARDING PERSONAL INFORMATION

    We may use or disclose your personal information without your specific authorization. Some of these situations are listed below. By law, we are, at times, required or allowed to share confidential information about you, even if you do not give permission. For other purposes, we will request your specific authorization in writing, which you may grant or reject. If granted, you can revoke the authorization at any time by letting us know in writing.

  • Reporting incidents of child or adult abuse or neglect to the police or other appropriate agencies;
  • Providing records when ordered to do so by a court;
  • Giving information to other agencies who review Chesterfields Services operations;
  • Sharing information needed by service providers or other agencies to determine if you are eligible for services or benefits;
  • Giving certain information to parents or guardians of minors;
  • Using information for research purposes;
  • Giving certain information to individuals who are directly involved in your care or payment for your care;
  • Giving information about you to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others.
  • CHANGES TO THIS NOTICE

    We reserve the right to change practices in this notice. If the law changes, we will send you a new notice about those changes. The new notice would apply to all the personal information about you that we maintain.

    ELECTRONIC NOTICE

    If you received this notice electronically, you may ask for a paper copy and we will provide one for you. To obtain a paper copy of this Notice, contact us as described below

    REPORTING A PROBLEM

    If you believe your privacy rights have been violated, or if you disagree with a decision we made about a request, you may file a written complaint with:

    Chesterfield Services Regional Director of Programs, 703 Columbia St., Seattle, WA, 98104. If you file a complaint, Chesterfield Services will not change or stop your services and may not retaliate against you.

    CONTACT INFORMAITON

    You may exercise any of your rights described in this Notice, or ask questions about these rights, by contacting us at:

    Chesterfield Services, Inc.,

    703 Columbia St., Seattle, WA, 98104,

    Telephone: 206-838-6050, Fax: 206-838-9777

    For directions to our offices, click CONTACT US.