Allied takes very seriously the value of the trust you have placed in working with us. This summary explains how we may use your Protected Health Information (PHI) and what your rights are regarding this information. Please read it carefully. This summary does not contain all of the details of our Privacy Practices. The complete text is available upon request or may be viewed on our website following this summary. It is important to read and understand the Notice of Privacy Practices before signing the Consent and Acknowledgment Form.

How we may use your PHI. Once we have let you know about our privacy practices, we may release the minimum necessary information to provide services to you, or for you, including fiscal intermediary services for Medicaid Waiver and Elder Homecare participants and for billing for services or Medicaid claim reimbursement. We need no further permission from you for the above activities. They are the same as we have always provided with the highest standards of confidentiality.

We may disclose your PHI without your authorization in certain limited cases, including to law enforcement officials, to comply with state laws relating to workers’ compensation programs and if we have reason to believe that your safety is at risk.

Fiscal Intermediary Services. Allied cannot obtain Medicaid reimbursement for your payroll funds, nor submit your quarterly tax reports and payments without providing some personal information. The only PHI – Protected Health Information that we have and use includes your name, address and FEIN Number for employer tax payments and reports and in order to process the Medicaid Claims for your employee payroll - a medical diagnosis code. We do not receive nor maintain any medical records for the Medicaid Waiver Program participants. As fiscal intermediaries, Allied's role and information is limited to the minimum necessary to accomplish our purpose as stated above.

Your Rights. You have the right to request a copy of your records or a change if you believe that your PHI is inaccurate. You can request that we send you information at a different address, or that only certain people receive information about you. Though we do what we can to honor your wishes, we are not required to agree to all your requests under all circumstances. If you believe your privacy has been violated, you may speak to Allied’s Privacy Officer, file a complaint with us or contact the office of the Secretary of the Department of Health and Human Services directly. Please see detailed instructions in the complete Notice.

If you have any questions about this Summary, our Notice of Privacy Practices, or would like further information concerning your privacy rights, please contact Allied Community Resources, Inc.’s Privacy Officer , Carol Bohnet, 6 Craftsman Road, East Windsor, CT 06088

(860) 627-9500 ext. 107 or email at cbohnet@alliedgroup.org

Important Notice of Privacy Practices
Allied Community Resources, Inc.

It is important to read and understand this Notice of Privacy Practices before signing
the Consent and Acknowledgment Form.

If you have any questions about this Notice or would like further information concerning your privacy rights,
please contact Allied Community Resources, Inc..

Allied Community Resources, Inc.
Carol Bohnet, Privacy Officer
6 Craftsman Road, East Windsor CT 06088
(860) 627-9500 ext. 107

Effective Date: April 14, 2003

Purpose of the Notice of Privacy Practices
This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information that we may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information.

Your “protected health information” is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.

We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information and to abide by the terms of the Notice that is currently in effect. However, we may change our notice at any time. The new revised Notice will apply to all of your protected health information maintained by us. You will not automatically receive a revised Notice. If you would like to receive a copy of any revised Notice you should access our web site at www.alliedgroup.org, contact Allied Community Resources, Inc. or ask at your next appointment or telephone contact with Allied.

How We May Use or Disclose Your Protected Health Information
Allied Community Resources, Inc. will ask you to sign a consent form that allows Allied Community Resources, Inc. to use and disclose your protected health information as required for payment operations and if applicable for service provision. You will also be asked to acknowledge receipt of this Notice.

The following categories describe some of the different ways that we may use or disclose your protected health information. Even if not specifically listed below, Allied Community Resources, Inc. may use and disclose your protected health information as permitted or required by law or as authorized by you. We will make reasonable efforts to limit access to your protected health information to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the protected health information to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such use or disclosure is limited by law.

• For Payment - We may use and disclose your protected health information so that we can bill and receive payment for the treatment and related services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid, or another third party payor. For example, we may need to give information about the treatment you received such as type, dates of services and provider name, so Medicaid will pay us or reimburse us for your treatment or for the payroll of your household employees, or we may contact the Department of Social Services or the CT State Medicaid Provider to confirm your coverage or eligibility.
• For Health Care Operations - We may use and disclose your health information as necessary for operations of Allied Community Resources, Inc., such as quality assurance and improvement activities, reviewing the competence and qualifications of auditing functions, and general administrative activities of Allied Community Resources, Inc.. For example, federal, state and outside CPA audits of Allied’s accounts.
• Business Associates - There may be some services provided by our business associates, such as a billing service, transcription company or legal or accounting consultants. We may disclose your protected health information to our business associate so that they can perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.
• Individuals Involved in Your Care or Payment of Your Care - Unless you object, we may disclose your protected health information to a family member, a relative, a close friend or any other person you identify, if the information relates to the person’s involvement in your health care to notify the person of payment related to your health care. In addition, we may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.
• Health Oversight Activities - We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure and disciplinary actions.
• Judicial and Administrative Proceedings - If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to your authorization or a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process if such disclosure is permitted by law.
• Law Enforcement - We may disclose your protected health information for certain law enforcement purposes if permitted or required by law. For example, to report suspicions of fraud, gunshot wounds; to report emergencies or suspicious deaths; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
• Research Purposes - Your protected health information may be used or disclosed for research purposes, but only if the use and disclosure of your information has been reviewed and approved by a special Privacy Board or Institutional Review Board, or if you provide authorization.
• To Avert a Serious Threat to Health or Safety - We may use and disclose your protected health information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.
• Workers’ Compensation - We may use or disclose your protected health information as permitted by laws relating to workers’ compensation or related programs.
• Special Rules Regarding Disclosure of Psychiatric, Substance Abuse and HIV-Related Information - For disclosures concerning protected health information relating to care for psychiatric conditions, substance abuse or HIV related testing and treatment, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or a court orders the disclosure.
• Mental health information. Certain mental health information may be disclosed for treatment, payment and health care operations as permitted or required by law. Otherwise, we will only disclose such information pursuant to an authorization, court order or as otherwise required by law. For example, all communications between you and a psychologist, psychiatrist, social worker and certain therapists and counselors will be privileged and confidential in accordance with Connecticut and Federal law.
• Substance abuse treatment information. If you are treated in a specialized substance abuse program, the confidentiality of alcohol and drug abuse patient records is protected by Federal law and regulations.
• HIV related information. We may disclose HIV related information as permitted or required by Connecticut law. For example, your HIV-related information, if any, may be disclosed without your authorization for treatment purposes, certain health oversight activities, pursuant to a court order, or in the event of certain exposures to HIV by personnel of Allied Community Resources, Inc., another person, or a known partner.
• Minors. We will comply with Connecticut law when using or disclosing protected health information of minors. For example, if you are an unemancipated minor consenting to a health care service related to HIV/AIDS, venereal disease, abortion, outpatient mental health treatment or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the use and disclosure of your health information.
  Other Uses of Medical Information - We may use or disclose your protected health information as permitted by laws relating to the Internal Revenue Service, Department of Revenue Services or related programs as it pertains to our fiscal intermediary and payment services.

When We May Not Use or Disclose Your Protected Health Information
Except as described in this Notice, or as permitted by Connecticut or Federal law, we will not use or disclose your protected health information without your written authorization.

Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, Allied Community Resources, Inc. may condition services on the provision of an authorization, such as for IRS, DRS and payroll related requirements. If you do authorize us to use or disclose your protected health information for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting Allied Community Resources, Inc.’s Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization.

Your Health Information Rights
You have the following rights with respect to your protected health information. The following briefly describes how you may exercise these rights.

• Right to Request Restrictions of Your Protected Health Information - You have the right to request certain restrictions or limitations on the protected health information we use or disclose about you. You may request a restriction or revise a restriction on the use or disclosure of your protected health information by providing a written request stating the specific restriction requested. You can obtain a Request for Restriction form from Allied Community Resources, Inc.. We are not required to agree to your requested restriction. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted protected health information is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and Allied Community Resources, Inc. may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restriction is only effective with respect to protected health information created or received after we have informed you of the termination.
• Right to Receive Confidential Communications - You have the right to request a reasonable accommodation regarding how you receive communications of protected health information. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. You may submit a request in writing to Allied Community Resources, Inc. requesting confidential communications. You can obtain a Request for Confidential Communications form from Allied Community Resources, Inc.
• Right to Access, Inspect and Copy Your Protected Health Information - You have the right to access, inspect and obtain a copy of your protected health information that is used to make decisions about your care for as long as the protected health information is maintained by Allied Community Resources, Inc.. To access, inspect and copy your protected health information that may be used to make decisions about you, you must submit your request in writing to Allied Community Resources, Inc.. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing or other supplies associated with your request. We may deny, in whole or in part, your request to access, inspect and copy your protected health information under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent professional designated by us to act as a reviewing official. This individual will not have participated in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs and attorney’s fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing such rights.
• Right to Amend Your Protected Health Information - You have the right to request an amendment to your protected health information for as long as the information is maintained by or for Allied Community Resources, Inc.. Your request must be made in writing to Allied Community Resources, Inc. and must state the reason for the requested amendment. You can obtain a Request for Amendment form from Allied Community Resources, Inc.. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial. We may rebut your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.
• Right to Receive An Accounting of Disclosures of Protected Health Information - You have the right to request an accounting of certain disclosures of your protected health information by Allied Community Resources, Inc. or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning on or after April 14, 2003 that is within six (6) years from the date of your request. The first accounting provided within a twelve-month period will be free. We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be given the opportunity to withdraw or modify your request for an accounting of disclosures in order to avoid or reduce the fee.
• Right to Obtain A Paper Copy of Notice - You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting Allied Community Resources, Inc.. In addition, you may obtain a copy of this Notice at our web site, www.alliedgroup.org.
• Right to Complain - You may file a complaint with us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you.

Allied Community Resources, Inc.
Carol Bohnet, Privacy Officer
6 Craftsman Road, East Windsor, CT 06088
(860) 627-9500 ext. 107