Effective July 1, 2015
Your Information. Your Rights. Our Responsibilities
While Building Arizona Families is not a medical provider, we may obtain medical records and/or information on their clients. Said medical information is then transmitted to all interested parties in the matter. Thus, we must comply with HIPPA guidelines. All information is transmitted through a HIPPA compliant server or transmitted in another HIPPA compliant mode of transmission. Business Associate Agreements are signed with the HIPPA compliant server and other required persons. As part of their compliance, we are required to post this privacy notice. 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.
Kelly Rourke, President/Executive Director
18355 West Ivy Lane
Surprise, Arizona 85388
Phone: (623) 936-4729
Fax: (623) 218-6014
How We Use Your Medical Information
We may obtain your medical records from your medical provider. We may also obtain medical information that you provide to us. Upon your signed release, this information is distributed to all parties who have an interest in the adoption including but not limited to your attorneys, agencies, social workers, medical providers, adoptive parent(s), birthparent(s), agencies, attorneys, and other state officials, including law enforcement authorities, medical providers and any other individuals involved in the adoption process. All transmissions are through a HIPPA compliant sever, via mail or facsimile or any other approved HIPPA compliant mode of transmission. Building Arizona Families never markets or sells your personal information.
You have the right to:
- Get a copy of your paper or electronic medical record
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information other than individuals or entities listed in your signed waiver of confidential 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
Our Uses and Disclosures
- We may use and share you information as we:
- Run our organization
- Comply with the law
- Comply with law enforcement and other government requests
- Respond to lawsuits and other legal actions
- Commence with lawsuits and other legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your 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. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Request confidential communications: 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 what we use or share: Request, in writing, not to use or share certain health information. We may say “no” if it would affect our ability to provide services or proceed in an adoption plan.
Get a list of those with whom we’ve shared information: Request, in writing, for a list of the times we’ve shared your health information other than individuals or entities listed in your signed waiver of confidential information
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 feel your rights are violated: You can complain if you feel we have violated your rights by contacting us. 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 www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Run our organization: We can use and share your health information to run our practice, provide services and proceed with an adoption plan.
How else can we use or share your health information? We are allowed or required to share your information in other ways. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
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’re complying with federal privacy law.
Address law enforcement, and other government requests: For law enforcement purposes or with a law enforcement official
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 or to commence with lawsuits or legal actions.
- We are required by law to maintain the privacy and security of your protected health information.
- 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.
- For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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.