WHAT THIS POLICY COVERS
2. This policy covers the collection, use, and maintenance of protected personal information for clients of Faith Mission, as an agency affiliated with the Community Shelter Board (CSB).
3. Protected Personal Information (PPI) is any personal information we maintain about a client that:
a. allows identification of an individual directly or indirectly;
b. can be manipulated by a reasonably foreseeable method to identify a specific individual; or
c. can be linked with other available information to identify a specific client.
4. We adopted this policy because the Department of Housing and Urban Development issued standards for Homeless Management Information Systems. We intend our policy and practices to be consistent with those standards. See 69 Federal Register 45888 (July 30, 2004).
6. We may amend our policy or practices at any time. Amendments may affect PPI that we obtained before the effective date of the amendment.
8. We maintain a copy of this policy on our website at www.faithmissionofohio.org.
HOW AND WHY WE COLLECT PERSONAL PROTECTED INFORMATION (PPI)
1. We collect PPI 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 individual case management;
b. to produce aggregate-level reports regarding use of services;
c. to track individual program-level outcomes;
d. to identify unfilled service needs and plan for the provision of new services;
e. to conduct research for planning and/or educational purposes; and
f. to accomplish any and all other purposes deemed appropriate by CSB.
2. We only use lawful and fair means to collect PPI.
3. We normally collect with the knowledge or consent of our clients. If you seek our assistance and provide us with PPI, we assume that you consent to the collection of information described in this policy.
4. We may also receive PPI about you from:
Columbus AIDS Task Force
Community Housing Network
Faith Mission/Faith Housing
Friends of the Homeless
Gladden Community House
Homeless Families Foundation
Lutheran Social Services
National Church Residences
Pater Noster House
Volunteers of America
5. We post a sign at our intake desk or other location explaining the reasons we ask for PPI. The sign says:
HOW WE USE AND DISCLOSE PPI
1. We use or disclose PPI for activities described in this part of the policy. We may or may not make any of these uses or disclosures of your PPI. We assume that you consent to the use or disclosure of your PPI for the purposes described below 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 or aggregate 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:
i. 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
ii. 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 in any of the following three circumstances:
i. where the disclosure is required by law and the disclosure complies with and is limited to the requirements of the law;
ii. if the individual agrees to the disclosure; or
iii. to the extent that the disclosure is expressly authorized by statute or regulation and either of the following are applicable:
A. we believe the disclosure is necessary to prevent serious harm to the individual or other potential victims; or
B. 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 PPI 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.
When we make a permitted disclosure under subparagraph (g) 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:
i. we, in the exercise of professional judgment, believe informing the individual would place the individual at risk of serious harm; or
ii. 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 our professional judgment.
h. 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:
i. in response to a lawful court order, court-ordered warrant, subpoena or summons issued by a judicial officer, or a grand jury subpoena;
ii. if the law enforcement official makes a written request for PPI that:
A. is signed by a supervisory official of the law enforcement agency seeking the PPI;
B. states that the information is relevant and material to a legitimate law enforcement investigation;
C. identifies the PPI sought;
D. is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and
E. states that de-identified information could not be used to accomplish the purpose of the disclosure.
iii. if we believe in good faith that the PPI constitutes evidence of criminal conduct that occurred on our premises;
iv. in response to an oral request for the purpose of identifying or locating a suspect, fugitive, material witness or missing person and the PPI disclosed consists only of name, address, date of birth, place of birth, social security number and distinguishing physical characteristics; or
A. the official is an authorized federal official seeking PPI for the provision of protective services to the President or other persons authorized by 18 U.S.C. 3056, or to foreign heads of state or other persons authorized by 22 U.S.C. 2709(a)(3), or for the conduct of investigations authorized by 18 U.S.C. 871 and 879 (threats against the President and others); and
B. the information requested is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought.
vi. to comply with government reporting obligations for HMIS and for oversight of compliance with HMIS requirements.
2. Before we make any use or disclosure of your PPI that is not described here, we seek your consent first.
HOW TO INSPECT AND CORRECT PPI
1. You may inspect and have a copy of your PPI that we maintain. We will offer to explain any information that you may not understand.
2. We will consider a request from you for correction of inaccurate or incomplete PPI that we maintain about you. If we agree that the information is inaccurate or incomplete, we may delete it or we may choose to mark it as inaccurate or incomplete and to supplement it with additional information.
3. We may deny your request for inspection or copying of PPI if:
a. the information was compiled in reasonable anticipation of litigation or comparable proceedings;
b. the information is about another individual (other than a health care provider or homeless provider);
c. the information was obtained under a promise of confidentiality (other than a promise from a health care provider or homeless provider) and if the disclosure would reveal the source of the information;
d. disclosure of the information would be reasonably likely to endanger the life or physical safety of any individual; or
e. if Faith Mission is unable to establish an individual’s identity.
4. If we deny a request for access or correction, we will explain the reason for the denial. We will also include, as part of the PPI that we maintain, documentation of the request and the reason for the denial.
5. We may reject repeated or harassing requests for access to or correction of PPI.
1. We collect only PPI that is relevant to the purposes for which we plan to use it. To the extent necessary for those purposes, we seek to maintain only PPI that is accurate, complete and timely.
2. We are developing and implementing a plan to dispose of PPI not in current use seven years after the information was created or last changed. As an alternative to disposal, we may choose to remove identifiers from the PPI.
3. We may keep information for a longer period if required to do so by an applicable statute, regulation, contract or other requirement.
COMPLAINTS AND ACCOUNTABILITY
1. We accept and consider questions or complaints about our privacy and security policies and practices.
Name of Resident/Client: ___________________________________ Date: _______________________
Faith Mission is committed to preserving the privacy and confidentiality of your PPI whether created by us or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your PPI. We are required by state and federal regulations to abide by the privacy practices described in the notice provided to you including any future revisions that we may make to the notice as may become necessary or authorized by law.
Effective Date of this Privacy Notice
The effective date of this Privacy Notice is: __________________________________________________
PRIVACY NOTICES, INFORMATION RESTRICTIONS, RECORD AMMENDMENTS, CORRECTIONS, DISCLOSURES OF INFORMATION, REVOKING AN AUTHORIZATION, INSPECTION AND COPYING OF RECORDS, CONFIDENTIAL COMMUNICATIONS, FILING COMPLAINTS, ETC.
Should you have any questions concerning our Agency’s privacy practices, obtaining copies of our Privacy Notice, requesting restrictions on the release of your information, revoking an authorization, amending or correcting your PPI, obtaining a listing of the information we disclose concerning your PPI, requests to inspect or copy your medical information, requests that we communicate information about your health/service matters in a certain way, denial of access to your PPI, filing complaints, or any other concerns you may have relative to our Agency’s privacy practices, please contact:
Client Rights Officer
245 N. Grant Ave.
Columbus, OH 43215
(614) 224-6617 (Phone)
(614) 388-5707 (Fax)
YOU MAY ALSO FILE COMPLAINTS WITH:
U.S. Department of Health and Human Services
23 N. Michigan Avenue
Chicago, IL 60601
(312) 886-2359 (Phone)
(312) 886-1807 (Fax)
(312) 353-5693 (TTD)
I certify that I have received a copy of this Agency’s Privacy Notice.
My Signature: _______________________________________ Date: _______________________
I certify that I am an authorized representative of ______________________________________________, and that I have received the Privacy Notice on behalf of this individual and that the Agency provided me with an opportunity review this document and ask questions to assist me in understanding his/her privacy rights.
Signature of Representative: _____________________________ Date: ______________________
FOR OFFICIAL USE ONLY
A good faith effort was made to provide a copy of the Privacy Notice to this resident/client, and, to obtain written acknowledgement of the same. Acknowledgement is not available for the following reason:
Staff Signature/Title:___________________________________________ Date: ____________________