Privacy Practices

Alaskan AIDS Assistance Association Notice of Privacy Practices

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

The Four A’s is not directly subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, we understand and recognize the need to adhere to the strictest level of confidentiality to maintain trust and the highest level of service. We have an ethical and legal commitment to our clients and the community to keep your information confidential. If you have any questions about this Notice please contact our Executive Director at (907) 263-2050 or by mail at Four A’s, 1057 West Fireweed, Suite 102, Anchorage, AK 99503. You may also contact the DHHS Office of Civil Rights at 200 Independence Avenue S. W., Room 509F, HHH Building, Washington D. C. 20201.

A. What This Notice Covers

1. The policy and practices in this notice cover the processing of protected health information for clients of The Four A’s
2. Protected Health Information (PHI) is any information we maintain about a client that:
   • a. allows identification of an individual directly or indirectly and is related to the past, present or future healthcare of that individual; or
   • b. can be linked with other available information to identify a specific client. When this notice refers to personal information, it means PHI.
3. We adopted this policy because of standards for Homeless Management Information Systems issued by the Department of Housing and Urban Development. We intend our policy and practices to be consistent with those standards. See 69 Federal Register 45888 (July 30, 2004).
4. This notice tells our clients, our staff, and others how we process personal information. We follow the policy and practices described in this notice. We also:
   • Keep your protected health information private;
   • Provide notice of our legal duties and privacy practices with respect to protected health information; • Notify affected individuals following a breach of unsecured protected health information;
   • Give you this Notice of Privacy Practices; and
   • Follow the terms of the Notice of Privacy Practices currently in effect.
5. We may amend this notice and change our policy or practices at any time. Amendments may affect personal information that we obtained before the effective date of the amendment.
6. We give a written copy of this privacy notice to any individual who receives services from The Four A’s. We maintain a copy of this policy on our website at (www.alaskanaids.org).

B. How and Why We Collect Personal Information

1. We collect personal information only when appropriate to provide services, or for another specific purpose of our organization, or when required by law. We may collect information for these purposes:
   • a. to provide or coordinate services to clients
   • b. to locate other programs that may be able to assist clients
   • c. for functions related to payment or reimbursement from others for services that we provide
   • d. to operate our organization, including administrative functions such as legal, audits, personnel, oversight, and management functions
   • e. to comply with government reporting obligations
   • f. when required by law
2. We only use lawful and fair means to collect personal information.
3. We normally collect personal information with the knowledge or consent of our clients. If you seek our assistance and provide us with personal information, we assume that you consent to the collection of information as described in this notice.
4. We may also get information about you from:
   • a. Individuals who are with you
   • b. Other private organizations that provide services (ANHC, ANMC, etc.)
   • c. Government agencies
   • d. Telephone directories and other published sources
5. We post a sign at our intake desk or other location explaining the reasons we ask for personal information. The sign says:
   

   We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information by law or by organizations that give us money to operate this program. Other personal information that we collect is important to run our programs, to improve services and to better understand the need of individuals. We only collect information that we consider to be appropriate.

C. How We Use and Disclose Personal Information

1. We use or disclose personal information for activities described in this part of the notice. We may or may not make any of these uses or disclosures with your information. We assume that you consent to the use or disclosure of your personal information for the purposes described here and for other uses and disclosures that we determine to be compatible with these uses or disclosures:
   • a. to provide or coordinate services to individuals
   • b. for functions related to payment or reimbursement for services
   • c. to carry out administrative functions such as legal, audits, personnel, oversight, and management functions
   • d. to create de-identified (anonymous) information that can be used for research and statistical purposes without identifying clients
   • e. when required by law to the extent that use or disclosure complies with and is limited to the requirements of the law
   • f. to avert a serious threat to health or safety if
     • 1) we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public, and
     • 2) the use or disclosure is made to a person reasonably able to prevent or lessen the threat, including the target of the threat
   • g. to report about an individual we reasonably believe to be a victim of abuse, neglect or domestic violence to a governmental authority (including a social service or protective services agency) authorized by law to receive reports of abuse, neglect or domestic violence
     • 1) under any of these circumstances:
       • a) where the disclosure is required by law and the disclosure complies with and is limited to the requirements of the law
       • b) if the individual agrees to the disclosure, or
       • c) to the extent that the disclosure is expressly authorized by statute or regulation, and
         • i. we believe the disclosure is necessary to prevent serious harm to the individual or other potential victims, or
         • ii. if the individual is unable to agree because of incapacity, a law enforcement or other public official authorized to receive the report represents that the PHI for which disclosure is sought is not intended to be used against the individual and that an immediate enforcement activity that depends upon the disclosure would be materially and adversely affected by waiting until the individual is able to agree to the disclosure.
     • and
     • 2) when we make a permitted disclosure about a victim of abuse, neglect or domestic violence, we will promptly inform the individual who is the victim that a disclosure has been or will be made, except if:
       • a) we, in the exercise of professional judgment, believe informing the individual would place the individual at risk of serious harm, or
       • b) we would be informing a personal representative (such as a family member or friend), and we reasonably believe the personal representative is responsible for the abuse, neglect or other injury, and that informing the personal representative would not be in the best interests of the individual as we determine in the exercise of professional judgment.
   • h. for academic research purposes
     • 1) conducted by an individual or institution that has a formal relationship with the Four A’s if the research is conducted either:
       • a) by an individual employed by or affiliated with the organization for use in a research project conducted under a written research agreement approved in writing by a designated Four A’s administrator (other than the individual conducting the research), or
       • b) by an institution for use in a research project conducted under a written research agreement approved in writing by a designated Four A’s administrator.
     • and
     • 2) any written research agreement:
       • a) must establish rules and limitations for the processing and security of PHI in the course of the research
       • b) must provide for the return or proper disposal of all PHI at the conclusion of the research
       • c) must restrict additional use or disclosure of PHI, except where required by law
       • d) must require that the recipient of data formally agree to comply with all terms and conditions of the agreement, and
       • e) is not a substitute for approval (if appropriate) of a research project by an Institutional Review Board, Privacy Board or other applicable human subjects protection institutions.
       • i. to a law enforcement official for a law enforcement purpose (if consistent with applicable law and standards of ethical conduct) under any of these circumstances:
         • 1) in response to a lawful court order, court-ordered warrant, subpoena or summons issued by a judicial officer, or a grand jury subpoena
       • and
         • 2) to comply with government reporting obligations for homeless management information systems and for oversight of compliance with homeless management information system requirements.
     • Before we make any use or disclosure of your personal information that is not described here, we will obtain a written authorization from you permitting us to do so.