AIP Intake Checklist

Notice of Privacy Practices

This notice describes how protected personal information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

As part of providing services to you, we will collect information about your care. We need this information to provide you with quality services and to comply with certain legal requirements. This notice applies to all the records of your care generated at Iris Family Support Center, including those in hard copy form, Web-based Systems and in Electronic Health Record Systems.

We are required by law to:

• Make sure personal information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to information about you
• Follow the terms of the Notice of Privacy Practices that is currently in effect

If you have any questions about this notice, please contact the person who coordinates your services, their supervisor, the program administrator or the CEO.

Main Office: Iris Family Support Center, 500 West Main Street, Fort Wayne IN 46802

The terms of this notice apply to all records containing your identifiable health information that are created or retained by Iris Family Support Center. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all your records Iris Family Support Center has created or maintained in the past and for any of your records that we may create or maintain in the future. We will post a copy of our current notice in each of our facilities in a prominent location. You may request a copy of our most current notice during any visit or by phone. The effective date of our notice will be posted in the upper left-hand corner of the notice.

Who Will Follow This Notice:

This notice describes the privacy practices of the entities that are part of Iris Family Support Center, including:

• Any professional authorized to enter information into your records
• Any members of a volunteer group that assists you while you receive services
• All employees, staff and other personnel

How We May Use and Disclose Information About you:

The following categories describe different ways that we use and disclose information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories listed below

For Your Care and Services

We may use health information about you to provide, coordinate or manage the services, support, and healthcare you receive from us and other providers. We may disclose health information about you to your medical care providers, your funding agency case manager, your SCAN, Inc. direct support staff, other agency staff or other peoplewho are involved in supporting you or providing care. For example, your direct care staff may need to share information about your services with your psychiatrist or with your case manager.

For Payment

We may use and disclose information about you so that services may be billed to and payment may be collected from you, an insurance company or other entity providing funding for your care. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For example, we may need to provide the state funding source with information about the services we provide so that we can be reimbursed for those services.

For Health Care/Service Operations

We may use and disclose information about you to run our program and to make sure you receive quality services, or to decide if we should change or modify our services. For example, we may disclose health information about you to train our staff. We may also use information for accreditation or licensing activities.

Release of Information to Family/Advocates

We may release your health information to an advocate or family member that is helping you pay for your care or who assists in taking care of you. In addition, we may disclose health information about you to an entity that is assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have specific objections or instructions regarding these communications, you may discuss them with us by contacting your service coordinator.

Research

We may use and disclose health information about you for research purposes in certain limited circumstances. All research projects are subject to a special approval process. Before we use or disclose health information for research, the project will have been approved through the research approval process. However, we may disclose health information about you to people preparing to conduct a research project, for example, to help them look for individuals with specific health needs, so long as the health information they review does not leave our premises. We will always ask for your specific permission if the researcher requests to have access to your name, address or other information that reveals who you are or who will be involved in your care. Your participation in research projects is voluntary

As Required by Law

We will disclose information about you when required to do so by federal, state or local law. For example, we may reveal information about you to the proper authorities to report suspected abuse or neglect.

To Avert a Serious Threat to Health or Safety

We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or of another person. Any disclosure, however, would only be to those able to help prevent the threat.

Military and Veterans

If you are a member of the armed forces, we may release information about you as required by military command authorities.

Workers' Compensation

We may release information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illnesses.

Public Health Activities

We may disclose information about you for public health activities. These activities generally include:

• The prevention or control of disease, injury or disability
• Reports of child abuse or neglect
• Notification that a person may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• Notifications to the appropriate authorities if we believe that you have been the victim of abuse, neglect or domestic violence

Health Oversight Activities

We may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for appropriate oversight of the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, or if there is a lawsuit or dispute concerning your services, we may disclose information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or, other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement

If asked to do so by a local, state or federal law enforcement official we may release health information:

• In response to a court order, subpoena, warrant, summons or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime in certain limited circumstances, if we are to obtain the person's agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at any facility where you are receiving treatment
• In emergency circumstances to report a crime (including the location or victim(s) of the crime, the description, identity or location of the perpetrator)

Coroners, Medical Examiners and Funeral Directors

We may release information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release information to funeral directors as necessary to carry out their duties.

National Security and Intelligence, Protective Services for the President and Others

We may release information about you to authorized Federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Correctional Programs

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official. This release would be necessary:

• for the institution to provide you with additional supports
• to protect your health and safety or the health and safety of others
• for the safety and security of the correctional institution

Your Rights Regarding your Protected Personal Information

You have the following rights regarding protected personal information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and receive a copy of your record that may be used to make decisions about your care, including your records and billing records.

To inspect and copy information that may be used to make decisions about you, you must submit your request in writing to your program director. If you need assistance, it will be provided to you. We may charge a reasonable, cost-based fee for copying records.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to information, you may request that the denial be reviewed. The CEO 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.

Right to Amend

If you feel that the information we have about you is incorrect or incomplete, you may ask us to amend the information. You must make your request for an amendment in writing and submit it to your program administrator. In addition, you must provide a reason that supports your request. If you need assistance to put your request in writing, it will be provided to you.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the information kept in your file
• We believe is accurate and complete

Right to an Accounting of Disclosures

We will keep a record of disclosures made on or after April 13, 2003, other than disclosures for treatment, billing, services, or health care operations. You have the right to request an “accounting of disclosures.”

Right to Request Restrictions

You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or a friend.

We are not required to agree to your request

If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, we encourage you to make your request in writing to your program administrator. If you need assistance, it will be provided to you. In your request, you must tell us:

• What information you want to limit
• Whether you want to limit our use, disclosure, or both
• To whom you want the limits to apply

Right to Request Confidential Communications

You have the right to request that we communicate with you about your services in a certain way or at a certain location. For example, you can ask us to contact you only at work o only by mail. You must make your request to obtain confidential communications in writing to your program administrator. You must specify how or where you wish to be contacted. If you need assistance, it will be provided to you. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact a member of your service planning team or contact the main office.

Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for information we already have about you as well as any information we receive in the future. The effective date will appear on the first page.

Complaints

If you believe your privacy rights have been violated, you may file an internal complaint via the grievance process at Iris Family Support Center. (See grievance procedures) which will initiate an Unusual Occurrence Report.

You may also file a complaint with the US Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Ave. SW, Washington, DC 20201.

All complaints must be submitted in writing. If you need assistance, it will be provided to you. You will not be penalized or retaliated against for filing a complaint.

Other users of Protected Personal Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.

If you provide us permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization.

You understand we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of that care that we provided to you.

Participant Rights & Responsibilities

Hours of Operations:
Monday - Friday 8:00 a.m. to 8:00 p.m.
Saturday 10:00 a.m. to 2:00 p.m.
Sunday Closed.
We are closed for major holidays.

Participant Rights

1. Participants have the right to be treated with dignity and respect without discrimination of race, color, gender, sexual orientation, religion, nation origin, veteran status, and/or handicap.
2. Participants have the right to receive services respectful of and responsive to learning, cultural and linguistic difference; Iris Family Support Center will accommodate in writing and oral communication the needs of participants in major service populations. Iris Family Support Center will attempt to do the same for other populations served. Iris Family Support Center will provide or arrange for, bilingual personnel or translators or arranging for the use of communication technology, as needed; providing telephonic amplification, sign language services, or other communication methods for deaf or hearing-impaired persons; providing, or arranging for, communication assistance for person with special needs who have difficulty making their service needs known; and considering the person’s literacy level.
3. Participants have the right to services that respect their personal values and choices
4. Participants have the right to choose to refuse services at any time
5. Participants have the right to participate in all service decisions, receive service in a manner that is non-coercive, and that protect their right to self-determination
6. Participants have the right to see their own records with a written request, a 24-hour notice, and a Iris Family Support Center staff person present. Participants may choose to be accompanied by a person of their choice, comment on the accuracy of the records, and insert their own statement(s) regarding the items in the records
7. Participants have the right to a referral for other services at any time; such a referral will contribute to services of the highest quality
8. Participants are entitled to have their rights explained to them using a language or method of communication they understand upon commencement of services
9. Participants have the right to choose to consent in writing prior to being recorded, photographed, or filmed

Agency Responsibilities

1. Iris Family Support Center promotes a culture of respect, healing and positive behavior for all our staff, children, parent/guardians, and visitors in home or within the agency. Iris Family Support Center will provide support to any individual that displays or identifies that the individual needs support to manage their own emotions and behaviors to prevent the need for crisis intervention in a respectful, healing and positive manner
2. Iris Family Support Center personnel are here to develop positive relationships with all service participants, our staff practice trauma-informed care, our staff build on your strengths of an individual and family unit and reinforce the positive attributes of individuals and family systems and will be responsive to all incidents to create a safe, respectful, healing and positive environment
3. Iris Family Support Center will consistently enforce all program rules and expectation for service recipients, including the video surveillance of its facilities. Video monitoring is used to protect property, maintain quality control, detect theft and misconduct, and discourage or prevent acts of harassment and violence
4. Visits will occur at a time agreed upon between participant and staff
5. Iris Family Support Center will ensure records are kept in a confidential manner according to all Mental Health and Developmental Disabilities Confidentiality Act, Chapter 2 of the Mental Health and Development Disabilities Code, and the Health Insurance Portability and Accountability Act (HIPAA); refer to Notice of Privacy Practices

Participant’s Responsibilities to Iris Family Support Center

1. Participant and/or parent/guardian agree to behave in a respectful, healing and positive manner to staff, children, other participants in the building. Participant agrees to notify staff or any individual need or needs of any individual family member with respect to the need for support to manage their own behaviors to prevent the need for crisis intervention
2. In Office: If I engage in threatening, aggressive (verbally or physically) behavior, I understand that I will be escorted out of the building by staff or police. If this occurs, a conference will be held with my referral source and a safety plan will be created to prevent any future need for crisis intervention
3. In Home/Community: If I engage in threatening, aggressive (verbally or physically) behavior in the home/community setting, I understand that the Iris Family Support Center worker will end the visit and call 911 if applicable. If this occurs, services will be discontinued until a conference is held with the program leadership and the referral source if applicable, and a safety plan will be created to support my emotional/behavioral needs
4. I agree to provide all relevant information as a basis for receiving services and participating in service decisions
5. I agree, that for quality of services and/or training purposes, there may be occasions when additional Iris Family Support Center staff may be present in my visit or other activity with Iris Family Support Center
6. I agree to call 24 hours in advance if I am unable to keep an appointment and give a reason for the cancellation
7. I agree to notify my Iris Family Support Center staff of changes to my contact information

Financial and Legal Obligations

1. Iris Family Support Center will not serve a minor without consent from a parent or legal guardian and provide this information upon request
2. Iris Family Support Center staff are mandated professional reporters and as such, are legally obligate to report alleged child abuse or neglect; per Indiana State Statute IC: 31-33 and Iris Family Support Center Policy
3. Iris Family Support Center staff are required to report any emergency situations involving a serious and/or imminent threat to the health and safety of the participant/others according to the Duty to Warn statute

Signatures

• I have received a copy of my rights, and I have had these rights explained to me in a language or method of communication that I understand
• I understand programs of Iris Family Support Center are provided without a direct cost to the participant and family served, other than those participating in Family Connections. Family Connections participants will receive a schedule of any applicable fees and estimated or actual expense prior to service delivery

Client Name

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Grievance Procedure for Individuals Receiving Services

You have the right to let your concerns (grievances) about how you are being treated be known.

You have a right to be told the method you can use to let your concerns (grievances) be known. This written notice is a description of how to report grievances and complaints about services you receive from Iris Family Support Center. This written notice will be given to you and/or your legal guardian before you begin receiving services with Iris Family Support Center.

You and/or your legal guardian are not limited to any way in the scope, content or frequency of your grievances.

You and/or your legal guardian may begin the grievance process by telling the person who coordinates your services what your complaint is either via phone, in person, in writing or via email.

General Expectations of Communication of Complaints is as Follows:

Oral Phase: Direct communication with the individual involved and/or their supervisor is expected, and follow-up will be initiated within the department. If the decision made in this phase is not satisfactory, the next phase can begin.

Written Phase: You may elevate your complaint in writing directly to the Program Leader. They will review the complaint and respond to you in writing within ten (10) business days. If the decision made in this phase is not satisfactory, the next phase can begin.

Meeting Phase: If you disagree with what the Program Leader decides, you may take your complaint via phone, in person, in writing or via email to the CEO. The CEO will make the final decision and respond to you and/or your legal guardian in writing within ten (10) business days.

If no resolution can be made, you may contact the Department of Child Services at: dcs.customerservice@dcs.in.gov

Address: Iris Family Support Center, 500 West Main Street, Fort Wayne IN 46802

Consent to Transport

When transporting children in car seats, only car seats provided by Iris Family Support Center may be used, unless the child has a medically required car seat prescribed by a professional.

Client Name

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Consent to Communicate

I give permission for Iris Family Support Center staff to call my emergency/alternate contacts at the following numbers:

I give permission for Iris Family Support Center staff to talk to the following people in my household during my home visitation services

Client Name

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Consent for Service

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Consent to Release & Request Information

Client Name

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BIP Goal and Treatment Plan

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UNCOPE

Demographics