Form DCF-2236 "Notice of Privacy Practices" - Connecticut

What Is Form DCF-2236?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Available in Vietnamese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCF-2236 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

ADVERTISEMENT
ADVERTISEMENT

Download Form DCF-2236 "Notice of Privacy Practices" - Connecticut

853 times
Rate (4.8 / 5) 60 votes
Notice of Privacy Practices
This notice describes how your medical information may be used and
DCF-2236
disclosed and how you can get access to this information.
04/03 (New)
Please review this notice carefully.
The Department of Children and Families (DCF) is federally mandated to maintain the privacy of your health information and wants you to know about DCF
practices for protecting your health information. DCF is required to follow the terms of this notice. The information DCF maintains may come from any of the
providers you see while you are a client of DCF. The information DCF records and maintains is known as Protected Health Information, or PHI. DCF will not use
or disclose your PHI without your authorization, except as described in this notice.
DCF reserves the right to change our practices and to make the new provisions effective for all Protected Health Information maintained. Should DCF information
practices change, DCF will amend the notice and make the notice available upon request or after the new effective date of the notice. This notice is effective as
of April 14, 2003.
Definitions
Individual refers to the person who is the subject of the
Treatment is the provision, coordination, or management of health
protected health information.
care and related services by one or more health care providers.
Payment consists of the activities undertaken by either a health plan
Protected Health Information means individually identifiable
or health care provider to obtain or provide reimbursement for the
information maintained or transmitted in any form.
provision of health care.
Authorization is the permission granted by the patient or the
Health Care Operations consist of the administrative, financial, and
patient’s guardian to use or disclose protected health
legal activities that support the essential health care functions of
information for purposes other than health care operations;
treatment and payment.
e.g., HIV testing or substance abuse screening.
Uses and
Your PHI is primarily used for:
Permitted disclosures of your PHI, without your authorization,
Disclosures
may include the following:
· Treatment - shared with another doctor for that treatment
· Abuse or Neglect and associated judicial proceedings
· Payment; e.g., to a pharmacy for medication
· Medical Research
· Health Care Operations – DCF internal quality efforts
· Law Enforcement
· Reminders to you of appointments for treatment or
treatment plan conferences or to provide information of
· Adjudicated Youth
interest to you about your treatment or health.
· Public Health
· Notification of a family member or guardian of where you are and
your condition.
What are your rights?
You (your parent or guardian) have the right to:
·
Request restrictions in writing on certain uses and disclosures of protected health information. DCF reserves the right to deny the restrictions.
·
Receive confidential communications of PHI by an alternative method; e.g., email notification.
·
Inspect and copy your health record by written request only.
·
Request amendment to your PHI.
·
Receive an accounting of DCF disclosures of your PHI.
·
Receive a paper copy of this notice upon request.
·
Revoke, in writing, an authorization at any time.
How can you report a problem?
If you feel your privacy rights have been violated, you may file a complaint in writing with the DCF Privacy Office, 505 Hudson Street, Hartford, CT 06106 or
with the Secretary of the Department of Health and Human Services (DHHS). There will be no retaliation for filing a complaint.
Would you like more information?
If you have questions and would like more information, you may contact the DCF Privacy Office at 1-866-360-1734.
I understand that my records are protected under the federal regulations contained in the Health Insurance Portability and Accountability Act of
1996 (HIPAA), Public Law 104-191.
I also understand that I may restrict or prohibit certain uses and disclosures at any time, except to the extent that action has been taken in
reliance on previously released information.
Signature of client/patient:
Date:
(or authorized representative when required)
Signature of DCF worker:
Date:
(confirmation that client received copy of notice)
Notice of Privacy Practices
This notice describes how your medical information may be used and
DCF-2236
disclosed and how you can get access to this information.
04/03 (New)
Please review this notice carefully.
The Department of Children and Families (DCF) is federally mandated to maintain the privacy of your health information and wants you to know about DCF
practices for protecting your health information. DCF is required to follow the terms of this notice. The information DCF maintains may come from any of the
providers you see while you are a client of DCF. The information DCF records and maintains is known as Protected Health Information, or PHI. DCF will not use
or disclose your PHI without your authorization, except as described in this notice.
DCF reserves the right to change our practices and to make the new provisions effective for all Protected Health Information maintained. Should DCF information
practices change, DCF will amend the notice and make the notice available upon request or after the new effective date of the notice. This notice is effective as
of April 14, 2003.
Definitions
Individual refers to the person who is the subject of the
Treatment is the provision, coordination, or management of health
protected health information.
care and related services by one or more health care providers.
Payment consists of the activities undertaken by either a health plan
Protected Health Information means individually identifiable
or health care provider to obtain or provide reimbursement for the
information maintained or transmitted in any form.
provision of health care.
Authorization is the permission granted by the patient or the
Health Care Operations consist of the administrative, financial, and
patient’s guardian to use or disclose protected health
legal activities that support the essential health care functions of
information for purposes other than health care operations;
treatment and payment.
e.g., HIV testing or substance abuse screening.
Uses and
Your PHI is primarily used for:
Permitted disclosures of your PHI, without your authorization,
Disclosures
may include the following:
· Treatment - shared with another doctor for that treatment
· Abuse or Neglect and associated judicial proceedings
· Payment; e.g., to a pharmacy for medication
· Medical Research
· Health Care Operations – DCF internal quality efforts
· Law Enforcement
· Reminders to you of appointments for treatment or
treatment plan conferences or to provide information of
· Adjudicated Youth
interest to you about your treatment or health.
· Public Health
· Notification of a family member or guardian of where you are and
your condition.
What are your rights?
You (your parent or guardian) have the right to:
·
Request restrictions in writing on certain uses and disclosures of protected health information. DCF reserves the right to deny the restrictions.
·
Receive confidential communications of PHI by an alternative method; e.g., email notification.
·
Inspect and copy your health record by written request only.
·
Request amendment to your PHI.
·
Receive an accounting of DCF disclosures of your PHI.
·
Receive a paper copy of this notice upon request.
·
Revoke, in writing, an authorization at any time.
How can you report a problem?
If you feel your privacy rights have been violated, you may file a complaint in writing with the DCF Privacy Office, 505 Hudson Street, Hartford, CT 06106 or
with the Secretary of the Department of Health and Human Services (DHHS). There will be no retaliation for filing a complaint.
Would you like more information?
If you have questions and would like more information, you may contact the DCF Privacy Office at 1-866-360-1734.
I understand that my records are protected under the federal regulations contained in the Health Insurance Portability and Accountability Act of
1996 (HIPAA), Public Law 104-191.
I also understand that I may restrict or prohibit certain uses and disclosures at any time, except to the extent that action has been taken in
reliance on previously released information.
Signature of client/patient:
Date:
(or authorized representative when required)
Signature of DCF worker:
Date:
(confirmation that client received copy of notice)