Client Privacy Practices

In compliance with HIPAA (The Health Insurance Portability and Accountability Act of 1996 [45 CFR]) and federal Substance Use client privacy rights [42 CFR Part 2].

If you are a client of Lutheran Family Services, this notice describes how LFS may use and disclose your information and how you can access this information. Please review this notice carefully.

Lutheran Family Services (LFS) tracks client information in individual client records. Your record may contain your symptoms, diagnoses, treatment plan, and other personally identifiable information. This record is the basis for planning your services. Your information may also be provided to third-party payers to verify that LFS provided billed services.

LFS will not disclose information from your client record without your authorization, except as described in this notice.

Treatment/Case Management – LFS will use your client record to provide you with services (e.g., to determine the best course of treatment). Your therapist/caseworker and other professionals will communicate with one another personally and through the client record to coordinate services. You may receive more than one service (program) during your time with LFS, with information shared between programs.

Payment – LFS will use your client record for payment for services rendered. The information on or accompanying the bill may identify you, as well as your services, diagnoses and/or treatment procedures. LFS will not use or disclose more information for payment purposes than is necessary. LFS is accountable to the Secretary of Health and Human Services to safeguard and protect client information.

Operations – LFS will use your client record for operations purposes (e.g., to assess the outcomes of your case and others like it) and to continually improve service quality and effectiveness. Regulatory and accrediting organizations may review your client record to ensure compliance with their requirements.
Notification – In an emergency, LFS may use or disclose your information to notify or assist in notifying a family member, personal representative, or another person responsible for you, of your location and general condition.

Workers’ Compensation – LFS may disclose your information to the extent authorized by and necessary to comply with workers’ compensation laws or other programs established by law.

Public Health – As required by federal and state law, LFS may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement – As required by federal and state law, LFS will notify authorities of alleged abuse/neglect, and risk or threat of harm to self or others. We may disclose your information for law enforcement purposes as required by law or in response to a valid subpoena.

Correctional Institution – Should you be an inmate of a correctional institution, LFS may disclose to the institution, or agents thereof, information necessary for your health and the health and safety of others.

Charges Against LFS – In the event you file suit against LFS, LFS may disclose information necessary to defend such action.

Duty to Warn – When a client communicates a serious threat of physical violence against himself, herself, or a reasonably identifiable victim or victims, LFS will notify either the threatened person(s) and/or law enforcement.

Health Information Exchange – LFS participates in one or more electronic health information exchanges, which permits LFS to electronically exchange health information about you with other participating providers (e.g., doctors and hospitals) and health plans and their business associates. For example, LFS may permit a health plan that insures you to electronically access your client record to verify a claim for payment for services, or LFS may permit a physician providing you care to electronically access your client record so they may have up-to-date information with which to treat you. Participation in a health information exchange also allows LFS to electronically access health information from other participating providers and health plans for our treatment, payment and health care operations purposes as described earlier in this Notice. In the future, LFS may allow other parties (e.g., public health departments that participate in the health information exchange) to access your health information electronically for their permitted purposes as described in this Notice.

LFS may also contact you about appointment reminders, treatment alternatives or for public relations activities.

In any other situation, LFS will request your written authorization before using or disclosing any identifiable information about you. If you choose to sign such authorization to disclose information, at any time you can revoke the authorization by providing that request in writing.

You have the following rights with respect to your protected health information (PHI):

1. You may request in writing that LFS not use or disclose your information for treatment, payment, or administration purposes, or to people involved in your services. However, LFS may use or disclose PHI to a health care provider to provide you with emergency
2. You may request in writing that LFS not use or disclose encounter information to your insurer if you have paid for services fully out of pocket without the use of your insurance benefits.
3. You may request that your health information be communicated to you in a confidential manner, such as sending mail to an address other than your home or by restricting phone calls.
4. Within the limits of Nebraska and Iowa statutes and regulations, you have the right to inspect and copy your protected health information. If you request copies, LFS will charge you a reasonable amount, as allowed by statute. For information that we hold electronically, you have the right to request an electronic copy of the information.
5. If you believe that information in your record is incorrect or missing, you have the right to request LFS correct or add that information.
6. You have the right to receive an accounting from LFS of certain disclosures of your protected health information:
   • Under 42 CFR Part 2, Substance Use clients may request an accounting of disclosures made with consent for up to three years prior to the date of the request, or a shorter period if you choose.
   • Under HIPAA, all other clients may request an accounting of disclosures of their Protected Health Information (PHI) for up to six years prior to the date of the request.
   • These exclude disclosures for treatment, payment, and operations, as well as those made with the client’s authorization. To request an accounting of your information that LFS used or disclosed that is not exempted from the accounting requirement, contact the LFS office nearest you.

7. If LFS sent this notice to you electronically, you may request LFS provide you with a paper copy.

1. LFS is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.
2. LFS is required by law to notify you when your protected health information has been, or is reasonably believed to have been, accessed, acquired, used, or disclosed in violation of privacy regulations.
3. LFS is required to abide by the terms of the Notice currently in effect.
4. LFS reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that it maintains. Prior to making any significant changes in our policies, LFS will change its Notice and post the new Notice in the waiting area and on our web site. You may also request a copy of this Notice at any time. For more information about our privacy practices, contact the LFS office nearest you.

If you believe LFS violated your privacy rights, or you disagree with a decision LFS made about access to your records, you may contact the LFS office nearest you or file a complaint/grievance here. You may also send a written complaint to the federal Department of Health and Human Services. LFS staff can provide you the appropriate contact information upon request. Under no circumstances will LFS retaliate against you for filing a complaint.

LFS is required by law to protect the privacy of your information, provide this Notice about our information practices, and follow the information practices described in this Notice. If you have any questions or complaints, please contact the LFS office nearest you.

At all times, you have the right to contact the following regulatory bodies to issue a complaint:

Council on Accreditation (COA) / Social Current
(212) 797-3000
coainfo@coanet.org
https://coa.formassembly.com/232264

Nebraska Department of Health & Human Services Regulation and Licensure
P.O. Box 95007
Lincoln, NE 68509-5007
(402) 435-2133

U.S. Department of Health & Human Services – Office for Civil Rights
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
(800) 368-1019
TDD toll-free: (800) 537-7697
https://ocrportal.hhs.gov/ocr/
Email for general / non‑privacy inquiries: OCRMail@hhs.gov
Email for Health Information Privacy / HIPAA inquiries: OCRPrivacy@hhs.gov