Notice of Privacy Practices for Protected Health Information

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.


Green Valley Association is required by law to maintain the privacy of your personal information and to provide you with this notice of our privacy practices.  We are required to abide by the terms stated in this notice but we reserve the right to change our privacy practices at any time.  You will be informed of these changes through a revised version of this notice which will be posted and available to you in each program and is posted on our web site at:


Please be advised that any reference to “you” and/or “your” in this notice means yourself or your ward, if you are the legal guardian of a person receiving services from GVA.



Use of Your Protected Health Information


Green Valley Association will use your information for treatment, service planning and coordination, obtaining payment, agency and program operations, and coordination of referrals.  For example, assessments and descriptions of preferences and behavior are used in your treatment planning.  Some information will be used in billing MaineCare or a private insurer.  Information will also be reviewed for quality assurance and in training new employees.


Business associates providing services on Green Valley’s behalf, mainly related to staff training, may also have access to your information when it is needed to provide that service after they have agreed in writing to assure the confidentiality of your information.


Green Valley Association may disclose your information without your authorization as permitted or required by law, including the following:  to comply with public health statutes and rules; to make required reports of abuse or neglect; to comply with oversight activities by federal and state governmental agencies; to comply with a court order; for research purposes; in the event of the individual’s death, to a medical examiner; to address a situation that seriously threatens health or safety; or for workers’ compensation purposes.


Green Valley Association may use your information to contact you or your representative about appointments, service planning, or other operational matters.  We may leave messages on your


answering machine or with another member of the household unless you request in writing that we do not.


Green Valley Association may also contact you as part of fund raising for the agency unless you request in writing that we do not.


Except as described above, we will not use or disclose your information until you have provided a written authorization to do so.  You may revoke an authorization at any time by submitting a verbal or written notice of your wish to revoke the authorization to the program manager.  Verbal revocations should be confirmed in writing as soon as possible.



Your Rights


·      You have the right to request reasonable restrictions on the use and disclosure of your information though we do not have to agree to any restriction.


·      You have the right to confidential communication with Green Valley Association.  If you wish special provisions be made in how communication is done with you, please submit your request in writing to the program manager.


·      You have the right to inspect and receive a copy of your information.  An opportunity to inspect your information will be provided within 30 days of our receiving a written request.  There will be a reasonable charge to cover the cost of making any copies or writing any summaries that you request.


·      You have the right to amend information in your records.  Please submit any proposed amendment in writing to the program manager.


·      You have the right to receive an accounting of any non-routine disclosures of your information.  Please make any request for this accounting to the program manager.


·      You have the right to a paper copy of this notice.  A copy of this notice can be obtained from any program site or our main office.  We will also mail a copy of this notice to you if you call and request it. 




·      You have the right to complain to us and to the U.S. Department of Health and Human Services if you believe that your privacy rights have been violated.      Complaints should be made in writing to the chief privacy officer.  The complaint should contain contact information for you, a description of the acts or omissions, identification of the employee(s) involved, locations involved, and the date(s) of the events.  Green Valley Association will not intimidate nor in any way retaliate against anyone making a complaint.



If you wish to receive more information or have any questions, please contact the chief privacy officer at the address below.


Green Valley Association chief privacy officer:


Jennifer Walker

Green Valley Association

PO Box 127

Island Falls, ME  04747

telephone:  207-463-2156
























Acknowledgment of Receipt of Green Valley Association’s

Notice of Privacy Practices for Protected Health Information


I acknowledge that I have received a copy of Green Valley Association’s Notice of Privacy Practices for Protected Health Information.  I understand that it is Green Valley Association’s policy to assure the confidentiality of all individually identifiable information unless I authorize a specific disclosure of information.  I understand that some disclosures are allowed or required under federal and state law. 


Signature of Acknowledgment:


_____________________________________                                  _______________________

   Individual or Authorized Representative                                                             Date



I am an authorized representative for: _______________________________________________