228 North Cascade Ave
Colorado Springs, CO 80903
As a client of Catholic Charities of Central Colorado, Life Connections, pursuant to 12 CCR 2509-8, § 7.710.53, you have the right to:
- Know the philosophy and religious affiliation of our agency.
- Have all of the legal options related to a pregnancy presented in an unbiased manner.
- Receive a written copy of our grievance procedure.
- Be referred to helping organizations in the community if you decide to parent your child.
- Terminate counseling with the agency and parent counselor at any time for any reason.
If you are considering adoption for your child, in addition to the above, you also have the right to:
- Have all of the legal options related to relinquishment procedures presented in an accurate, competent, unbiased manner
- Have a fair and balanced picture of adoption presented.
- To make the decision related to the possible relinquishment of your child(ren) in an atmosphere free from coercion and undue pressure.
- Know that you have the option, by law to change your decision about relinquishment and to choose to parent your child. Your decision can be changed at any time prior to the final order of relinquishment being signed by the court, unless otherwise limited by a court order if a court hearing is held. You have the right to withdraw an affidavit of expedited relinquishment at any time before an expedited relinquishment affidavit is filed with the court. The petition for relinquishment may not be filed until at least four (4) calendar days after the birth of the child.
- To seek independent counsel on any issue related to the relinquishment of your child(ren), including the right to seek independent counseling for an expedited relinquishment procedure.
- To receive a copy of any document signed by you, and to receive a copy of the original birth certificate
- To receive in writing the process by which an expedited relinquishment affidavit is withdrawn, including a personal meeting with a representative of the agency and the signing of a statement of withdrawal which is witnessed and signed by an agency representative. A copy of the statement with original signatures will be provided to you.
- In a designated adoption 1) to change your mind for any reason at any time prior to signing a release of parental rights in court; 2) have the right to request and review other Catholic Charities’ prospective adoptive parent profiles for your consideration; and 3) have the right to select and place for adoption with a family of your choice if that is your wish.
228 North Cascade Ave
Colorado Springs, CO 80903
Catholic Charities of Central Colorado, Inc.
Notice of Privacy Rights
During the process of providing services to you, Catholic Charities of Central Colorado, Inc. (CCCC) will obtain, record, and use mental health and medical information about you that is protected health information. Ordinarily that information is confidential and will not be used or disclosed, except as described below. This Notice is required by a federal law known as HIPAA and describes how we may use and disclose your protected health information in accordance with that law. CCCC is required to abide by the terms of this Notice, or any amended Notice that may follow. This Notice is effective September 23, 2013.
CCCC is required by State and Federal law to maintain the privacy of protected health information. CCCC is required by law to provide clients with notice of our legal duties and privacy practices with respect to protected health information. There are circumstances where other state and federal laws are more stringent (strict) than HIPAA, and in such cases, we will follow those laws with respect to the limitation on uses and disclosures of your information. We will notify you of a breach of your unsecured protected health information.
Uses and Disclosures
CCCC may use and disclose protected health information without your consent in the following ways.
Treatment. We will use and disclose your health information to provide, coordinate, or manage health care (including mental health care) and related services. For example, staff involved with your care may use your information to plan your course of treatment and consult with other staff to ensure the most appropriate methods are being used to assist you.
Payment. We will use and disclose your health information for payment purposes. For example, we will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company for services provided. The information provided to insurers and other third party payers may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment.
Health Care Operations. Health Care Operations refers to activities undertaken by CCCC that are regular functions of management and administrative activities. For example, we may use and disclose your health information in monitoring of service quality, staff training and evaluation, medical reviews, legal services, auditing functions, compliance programs, business planning, and accreditation, certification, licensing and credentialing activities.
Contacting the Client. We may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.
Required by Law. CCCC will disclose protected health information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect; (b) when a court orders us to release information; (c) when there is a legal duty to warn or take action regarding imminent danger to others; (d) when required to report certain communicable diseases and certain injuries; and (e) when a coroner is investigating a client’s death.
Health Oversight Activities. CCCC will disclose protected health information to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, regulatory programs, or determining compliance with program standards.
Family Members. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
Crimes on the premises or observed by CCCC personnel. Crimes that are observed by our staff, which are directed toward staff, or occur on CCCC’s premises, will be reported to law enforcement.
Business Associates. Some of the functions of CCCC are provided by contracts with business associates. For example, some administrative, clinical, quality assurance, billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. Business associates are required to enter into an agreement maintaining the privacy of protected health information.
Research. CCCC may use or disclose protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulation are followed. 45 CFR § 164.512(i).
Involuntary Clients. Pursuant to state law, information regarding clients who are being treated involuntarily will be shared with other treatment providers, legal entities, third party payers, and others as necessary to provide care and case management coordination.
Fundraising. CCCC may contact clients as a part of its fundraising activities. You may opt-out of receiving such communications.
Emergencies. In life threatening emergencies we may disclose information necessary to avoid serious harm or death.
Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from CCCC by alternative means or at alternative locations. For example, if you do not want the Agency to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask Agency staff for the appropriate request form.
Choose someone to act for you.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
CCCC may not disclose protected health information in any way other than as described in this Notice without written authorization. Examples include certain disclosures of psychotherapy notes, marketing communications, and disclosures that constitute a sale of your information. You may revoke authorizations at any time except to the extent CCCC has already used or disclosed such information.
Your Privacy Rights
You have rights with respect to your protected health information. To exercise any of these rights, contact the CCCC Records Manager at (719) 866-6535.
Access to Your Information. You have the right to inspect and obtain a copy of the protected health information we maintain about you. There are some limitations to this right, which will be explained to you at the time of your request, if applicable.
Amendment of Your Record. You have the right to request that CCCC amend (correct) your protected health information. We are not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be explained to you at the time of your request, if relevant, along with the appeal process available to you.
Accounting of Disclosures. You have the right to know when we have disclosed your information without your consent for purposes other than treatment, payment, and health care operations. There are other exceptions that will be explained to you, if applicable.
Request Restrictions. You have the right to request additional restrictions on the use or disclosure of your health information. We do not have to agree to that request unless you ask us to restrict disclosure to a health plan that 1) is for payment or health care operations purposes and is not otherwise required by law, and 2) the protected health information relates solely to a health care item or service for which you paid us in full.
Confidential Communications. You have the right to request that we communicate with you by alternative means or at alternative locations. For example, if you do not want us to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be explained to you at the time of the request process, if applicable.
Copy of this Notice. You have a right to obtain another copy of this Notice upon request.
Confidentiality of Alcohol and Drug Abuse Patient Records.
The confidentiality of alcohol and drug abuse patient records maintained by this Agency is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:
- The patient consents in writing:
- The disclosure is allowed by a court order; or
- The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
Violation of the Federal Law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
(See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations). (Approved by the Office of Management and Budget under Control No. 0930-0099).
If you believe CCCC has violated your privacy rights, you have the right to file a complaint with
CCCC. To file your complaint, call the CCCC Privacy Officer, Jennifer Kleinschmidt at (719) 636-2345. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
Changes to this Notice
CCCC reserves the right to change the terms of this Notice and to make the new provisions effective for all protected health information that we maintain. When the Notice is revised, the revised Notice will be posted in CCCC facilities and on our website.