Privacy Statement

Effective April 14, 2003
ARC Gateway, Inc.
PRIVACY NOTICE

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

Note to Guardians: Please note that when this notice refers to "you" and "your", we are referring to your ward who is receiving services at ARC Gateway, Inc. and his/her protected health information.

If you have any questions concerning this notice, please contact the following:

For Pollak Industries, Pollak Training Center , Senior Adult Program, Community Based Employment and Employment Services, call:
Employment and Day Services Director
ARC Gateway, Inc.
3916 N. 10th Avenue
Pensacola , FL 32503
Phone (850)434-2638

For Palace, Group Homes, Supported Living, In-Home Supports, call:
Community and Residential Director
ARC Gateway, Inc.
3916 N. 10th Avenue
Pensacola , FL 32503
Phone (850)434-2638

Introduction

In order to provide health care services, ARC Gateway must obtain and maintain protected health information from you. This Notice of Privacy Practices describes the types of information that is collected and your rights with regards to that information. ARC Gateway, Inc. is required by law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices with respect to that protected health information.

Our pledge regarding health information

We understand that medical information about you and your health is personal. We are committed to protecting such medical information about you. We create a record of the care and services you receive here at ARC Gateway, Inc. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by ARC Gateway, Inc.

This notice describes how we may use and disclose your protected health information in order to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

Definitions

Protected Health Information

"Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Protected health information includes the following:
. Your health history
. Your medical records
. Your name, address and date of birth
. Your marital status
. Your gender
. Your social security number
. Other similar information that relates to past, present, or future medical care

Health Information

Health information is any information, whether oral or recorded in any form or medium, that:
1. Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse;
and
2. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual

Who Will Follow This Notice

The following people will be required to follow the requirements of this Policy Notice:

. All employees of ARC Gateway, Inc.
. Any volunteers we allow to work with you
. Any Business Associate allowed access to your Protected Health Information

Sources of Protected Medical Information

Your protected medical information is obtained from a variety of places. These sources include:

. Applications you have completed for health care coverage
. Reports and correspondence from your physician(s)
. Information obtained from your pharmacist
. Information from you, obtained in writing or over the telephone, or in person
. Information from your health insurance company/plan or their representative
. Information obtained from your support coordinator
. Information obtained from anyone involved in your referral to our agency
. Information from other entities involved in your health care
. Information from the Escambia School District
. Information from the Department of Children and Families
. Information from Vocational Rehabilitation
. Information from the Social Security Administration
. Information from Medicaid
. Information from the program serving you at ARC Gateway
. Information from other service providers

Uses and Disclosures of Protected Health Information

ARC Gateway will, as allowed by privacy regulations, use and disclose your personal health information for the treatment, payment and health care operations.

Your protected health information may be used and disclosed by ARC Gateway in order to provide you with services, obtain payment for services and in the health care (business) operation of ARC Gateway.

These treatment, payment, and health care operations include (but are not limited to):

. Treatment of your health condition
. Provision of your service(s)
. Billing for your services to the following sources:
. Medicaid Waiver
. Dept. of C&F
. Escambia County School District
. Vocational Rehabilitation
. Devcon
. Able Trust
. Other funding sources
. Coordination of benefits/services with other providers
. Eligibility for coverage issues
. Business planning and development
. Budget meetings
. Complaint review
. Safety Committee Reviews
. Board of Directors meetings
. Board of Directors committee meetings
. Regulatory review and legal compliance
. Review by Service Coordinator
. Individual Support Plan meetings
. Funding Source monitoring/reviews
. Program staff meetings concerning your services
. Medication review by a pharmacist
. Nursing assessment

The following categories describe different ways that we may use and disclose medical information about you. For each category of use/disclosure, 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 of the ways we are permitted to use and disclose information will fall within one of the categories.

Use and disclosures for treatment and services: We may use medical information about you to provide you with treatment and services. Your protected health information may be disclosed to health care providers including doctors, nurses, therapists, pharmacists, laboratory technicians, and other health care personnel involved in your services. It will be disclosed to the agencies funding your service and your support coordinator. It may also be disclosed to other service providers involved in your care.

Uses and disclosures for payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan or funding source may undertake before it approves or pays for the health care and other services. This includes making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and eligibility, and undertaking utilization review activities. For example, approval for a therapy service may require that your relevant protected health information be disclosed to your health plan. Approval for your services here at ARC Gateway may require disclosure of your protected health information to funding sources and your support coordinator. Your protected health information may be used, as needed to obtain payment through Medicaid Waiver, Dept of C&F, Vocational Rehabilitation, Escambia County School District , Devcon and other funding sources.

Uses and disclosures for health care operations: We may use and disclose medical information about you for operational and business purposes. These uses and disclosures are necessary to provide our services and make sure all the people we serve receive quality care. The information may be used and disclosed for assessments, evaluations, business planning, staffings, ISP meetings, VR meetings, IEP meetings, monitoring by funding sources and their agents, conferences with Service Coordinator, supervisor/peer review of consumer files for accuracy, audits, legal services, Board of Directors meetings, committee meetings, Managers' meetings, nursing assessments, medication reviews, or administrative services. We may list your name and demographic information in lists of people served, which are shared with other personnel in the agency (such as the accounting office, HR office, administration, managers meetings, etc.).

We may share your protected health information with our business associates who are hired by us to perform various services for us. These business associates include accreditation agencies, consultants, auditors, monitoring agencies, attorneys and others as necessary to carry out treatment, billing and health care operations. Whenever an arrangement between our agency and a business associate involves the use or disclosure of your protected health information, we will require the business associate to sign an agreement that contains terms that will protect the privacy of your protected health information.

We may combine your medical information with other medical information so others may use it to study health care, health care delivery and services without being able to identify individuals.

In order to ensure the privacy of your protected health information, ARC Gateway has developed privacy policies and procedures. Procedures are based on appropriate administrative, technical and physical safeguards necessary to maintain confidentiality of your protected health information. Such information is limited to those individuals that have a legitimate business need for that information. This protection extends to use of your protected health information by ARC Gateway business partners.

Non-routine disclosures of personal health information

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. For example, if we use your personal health information for solicitation of funds from agencies such as United Way , City of Pensacola , or Escambia County , we will obtain your authorization. If we use your information for public relation purposes or reporting purposes (such as the monthly newsletter, the staff newsletter, the annual report, brochures), we will obtain your authorization. ARC Gateway will use or disclose information in these circumstances pursuant to the specific purpose contained in your authorization and will only use or disclose the minimum amount of information necessary to perform the non-routine function. You may revoke this authorization, at any time, in writing, except to the extent that ARC Gateway has taken action in reliance on the use or disclosure indicated in the authorization.

In most circumstances, authorization may only be made by the person to whom the protected health information pertains (or if legally incompetent, the legal guardian). In some circumstances, authorization may be obtained from a person representing your interests (such as in the case where you may be too incapacitated to make an informed authorization) or in emergency situations where authorization would be impractical to obtain.

Other Permitted and Required Uses and Disclosures That May be Made With Your Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, as in the case of an emergency, we will rely on our professional judgement. In this case, only the protected health information that is relevant to your health care will be disclosed.

In the following instances, we may use and disclose your protected health information if you have not objected:

Others Involved in Your Healthcare or Services:
Unless you object, we may disclose to a member of your family, a relative, a close friend, a caretaker (such as an individual from your group home) or any other person that you identify, your protected health information that directly relates to that person's involvement in your health care/services. If you are unable to agree to or object to such a disclosure, we may disclose such information as necessary if we determine based on our professional judgement that it is in your best interest. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care/services.

Emergencies:
We may use or disclose your protected health information in an emergency treatment situation. If this happens, the staff at your program will try to obtain your consent as soon as reasonably practicable after delivery of treatment.

Communication Barriers:
We may use and disclose your protected health information if the Support Staff at your program attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the Support Staff determines, using professional judgement, that you intend to consent to use or disclosure under the circumstances.

Other Permitted and Required Uses and Disclosures That May be Made Without Your Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your authorization. The following list is covered in greater detail below.

The following non-routine disclosures may be made without your authorization to:

. Law enforcement personnel in response to legal requirements
. Legal representative in response to a court order or other legal proceeding
. Public health agencies
. Abuse/Neglect
. Coroners, medical examiners, funeral directors
. Organ donation and tissue transplant entities, if you are an organ or tissue donor
. Research
. Personal and Public Safety
. The military if you are a member of the armed services
. Workers' compensation carriers
. Correctional institutions if you are an inmate
. National security and intelligence agencies as authorized by law

Required by Law:
We may use or disclose your protected health information to the extent that the use or disclosure is required by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Law Enforcement:
We may also disclose medical information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include:

. Legal processes and as otherwise required by law
. Limited information requests for identification and location purposes
. Pertaining to victims of a crime
. Suspicion that death has occurred as a result of criminal conduct
. In the event that a crime occurs on our premises
. Medical emergency (not on the premises) and it is likely that a crime has occurred

Legal Proceeding:
We may disclose your medical information in response to a court order, subpoena or other legal proceeding.

Public Health:
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases:
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight:
We may disclose protected health 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 the government to monitor the health care system, government programs, and compliance with civil rights laws.

Food and Drug Administration:
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.

Abuse or Neglect:
We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child (or disabled adult) abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of the applicable federal and state laws.

Coroners, Funeral Directors, and Organ Donation:
We may release medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose medical information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for organ, eye or tissue donation purposes.

Research:
Under certain circumstances, we may use and disclose medical information about you to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Personal or Public Safety:
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military and Veterans:
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. If you are a member of the Armed Forces, we may disclose medical information about you to the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is necessary for the Department of Veterans Affairs to determine if you are eligible for disclosure for certain benefits. If you are enrolled for community based services through the Department of Veteran Affairs, we may use and disclose to the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits, for treatment, for payment and for agency operations.

Workers' Compensation:
Your protected health information may be disclosed by us, as authorized by law, to comply with workers' compensation laws and other similar legally established programs.

Inmates:
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for safety and security of the correctional institution.

National Security and Intelligence Activities:
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Required Uses and Disclosures:
Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et.seq. (HIPAA regulations).

Your Rights Regarding Medical Information About You

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

Right to Inspect and Copy:
You have the right to review your protected health information maintained by ARC Gateway and to obtain a copy of such information.

Under federal law, however, you may not inspect or copy the following records:

1) psychotherapy notes;
2) information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

There are also limited circumstances where we may deny access.

The denial would be for such circumstances as:
1) if a licensed health care professional has determined that the access requested is reasonably likely to endanger the life or physical safety of the person served or another individual;
2) the protected health information makes reference to another person (other than ARC staff, Support Coordinator or other provider) and a licensed health care professional has determined that access is reasonably likely to cause substantial harm to such other person;
3) the information revealed will reveal protected health information about another person served; or
4) the request was made by the individual's personal representative and a licensed health care professional has determined that access to such personal representative is reasonably likely to cause substantial harm to the person served or another person.

To inspect and copy medical information, you must submit your request in writing to our Privacy Contact. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

If we deny your request for access for the reasons stated above, we will notify you in writing. You have the right to have the request reviewed by a licensed health care professional who is designated by ARC Gateway to act as a reviewing official and who did not participate in the original decision to deny.

Right to Amend:
You also have the right to request amendments to your protected health information if you feel the information is incorrect or incomplete. Requests for amendments must be made in writing and must include a reason for the requested amendment. You must submit the request to the Privacy Contact listed on the first page of this notice. You have the right to request an amendment for as long as the information is kept by our agency.

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 that person or entity that created the information is no longer available to make the amendment
. Is not part of the medical information kept by or for our agency
. Is not part of the information which you would be permitted to inspect and copy; or
. Is accurate and complete

Right to an Accounting of Disclosures:
You have a right to request an accounting of disclosures (other than those for treatment, billing and business operations or those authorized by you) of your protected health information made by ARC Gateway. This request must be made in writing and submitted to the Privacy Contact listed on page one of this notice. Your request must state a time period, which may not be longer than six years, and may not include dates before April 14, 2003 . The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions:
You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree to the restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Contact listed on the first page of this notice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; (3) to whom you want the limits to apply, (for example, disclosures to your spouse).

Right to Request Confidential Communications:
We routinely use the phone numbers you or your Support Coordinator has given us when we contact you. If you want us to contact you elsewhere, you have the right to request that communications regarding your protected health information from ARC Gateway be made at a certain time or location if you do not want us to use the numbers we have on file for you. If you want us to contact you elsewhere, you must specify how or where you wish to be contacted. You may also request that meetings be held in a confidential setting. This request must be in writing to the Privacy Contact listed on page one of this notice. For example, if you prefer not to get reminders of appointments at work, you may make that request. We will accommodate all reasonable requests.

Changes to Privacy practices

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at your program. The notice will contain, on the first page, in the right hand corner, the effective date. You may request a copy of the current notice at any time from your Program Manager.

Up-to-date privacy notices are maintained on the ARC Gateway web site.

Complaint Procedure

If you feel your rights under this Notice of Privacy Practices have been violated in any way, please contact the Privacy Contact (see page one), or the ARC Gateway Privacy Official below:

Privacy Official
Administrative Services Director
ARC Gateway, Inc.
3916 N. 10th Avenue
Pensacola , FL 32503
(850) 432-8404

All complaints must be in writing, explaining how we have violated your Privacy Rights.

There will be no retaliation of any kind for complaints submitted under this Privacy Notice.

ARC Gateway
3932 North Tenth Avenue
Pensacola, FL 32503
(850)434-2638