This notice describes how personal/private information (PPI) information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your RightsWhen it comes to your personal information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your Case Management file
•You can ask to see or get a copy of your Case Management file and other personal information we have about you.
•We will provide a copy or a summary of your personal information, usually within 30 days of your written request.
Ask us to correct your Case Management file
•You can ask us to correct personal information about you that you think is incorrect or incomplete.
Request confidential communications
•You can ask us to contact you in a specific way (for example, home or office phone). We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
•All information will remain confidential except in the following circumstances: danger of one acting on suicidal or homicidal thoughts, suspected child or vulnerable adult abuse or neglect, or court subpoena.
•You can ask us not to use or share certain personal information for our referral services or our operations.
•JJAB shares only de-identified information with organizations/grants that provide funding for our programs. This can include a birth month and/or year, ethnicity, and/or zip code/city of residence.
Choose someone to act for you
•If you have given someone power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your service referral.
•We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
•If you feel your rights have been violated, you can make a complaint by contacting us directly.
•You may 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/.
•We will not retaliate against you for filing a complaint.
Your ChoicesYou have a right and a choice regarding sharing any of your information. For certain information, you can tell us your choices about what we may share. If you have a clear preference for how we share your information in the situations described below, talk to us.
For JJAB to share any information with any person or organization, except in the circumstances defined above, you must sign a Release of Information. A Release of Information is a document signed by you, where you explicitly state with whom we can share information about you. This may allow us to share information with your family, close friends, your school or others involved in your care.
Our Uses and DisclosuresHow do we typically use or share your personal information?
We can use your personal information and share it with other professionals for referral purposes. Example: A Resource Specialist may refer you to a doctor if you identify a need for services.
Run our organization
We can use and share your personal information to improve your care and contact you when necessary. The organization is the owner of all official JJAB documents which are kept confidential as directed by privacy rules.
Obtain funding for the programs used to aid and support you
JJAB shares de-identified information with organizations/grantors that provide funding for our programs. This information can include a birth month and/or year, gender, ethnicity, tribal affiliation and/or zip code/city of residence.
We can share personal information about you under certain situations such as:
•Reporting suspected abuse or neglect.
•Preventing or reducing a serious threat to health or safety.
Do research or for program development
We can use or share de-identified information for program development. Example: JJAB may report compiled data such as - 24 Youth expressed a need for walk-in mental health services.
Comply with the law
We will share information about you if state or federal laws requires this. It may include, but not be limited to, sharing information with the Department of Health and Human Services in order for the agency to verify that we are compliant with federal privacy law.
•For law enforcement purposes or with a law enforcement official.
•With oversight agencies for activities authorized by law.
Respond to lawsuits and legal actions
We can share information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities•We are required by law to maintain the privacy and security of your protected personal information.
•We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Revision Date 03/01/2018
The Youth and Family Resource Specialists offer case management and community resource services to children, youth, and their families. Resource Specialists assist clients in connecting to services and resources and, whenever possible, finding support within the community.
In order for JJAB to provide effective client services, I provide consent to services and authorize the mutual exchange of information regarding my child with the JJAB Resource Specialist for the purposes of providing case management services and referrals for resources.
To promote an effective working relationship, the Resource Specialist may conduct intake and exit meetings and request participation in client assessments and/or program feedback surveys. As with all Resource Specialist services, client/caregiver participation in assessments or surveys is voluntary.
We have discussed how we will handle casual encounters.
This authorization may be revoked at any time by submitting a written request to JJAB Resource Program (P.O. Box 4716, Los Alamos, NM 87547). I hereby certify that this request has been made voluntarily.
JJAB Resource Specialist: ____________________________________ Date ___________
Parent Release of Information: For the purpose of coordination of client resources and services, as the legal guardian and/or custodial parent of above named child, authorize JJAB Resource Specialist to release and to obtain information from regarding said minor child between the Los Alamos JJAB Resource Specialist and the following person(s):
Client Release of Information (if age 18): For the purpose of coordination of client resources and services, I authorize JJAB Resource Specialist to release and to obtain information from the following person(s):
Information being requested may be released verbally and in writing. This authorization may be revoked at any time by submitting a written request to the LA JJAB Resource Program at P.O. Box 4716, White Rock, NM 87547 or at email@example.com. I hereby certify that this request has been made voluntarily.
JJAB Resource Specialist: __________________________________ Date ____________
As a registered client of the Los Alamos JJAB, you have the following rights and responsibilities. Please review, discuss and sign your agreement to them.
1. You have the right to services and cannot be discriminated against based on race, religion, creed, color, national origin, gender, pregnancy, sexual orientation, gender identity, age, ancestry, physical or mental disability, genetic information, marital status or any other classification protected by local, state or federal law.
3. Regarding Resource Specialist (RS) services, you have the right to:
a. Request information relating to services offered by JJAB and the availability of other services offered in Los Alamos and surrounding counties.
b. Receive an explanation of how the RS will work with you and your family to access community service providers through referrals, JJAB Programs, and community services.
c. Be notified by JJAB/RS, if an accident, injury or illness occurs to your child/teen during the time of an interaction with an RS, of which the RS has knowledge.
Clients’ Responsibilities:1. It is your responsibility to complete and update all JJAB paperwork.
2. It is your responsibility to communicate with your RS any changes in your or your child/teen’s situation that may impact current services or the nature of services needed.
3. If you wish participation of your RS at any school‐related meetings for your child/teen, it is your responsibility to request the RS’s support and assistance.
4. It is your responsibility to request a change to services, including but not limited to type of services, a change in service provider, and/or change of RS.
5. You will need to understand that other community‐based services that JJAB refers you/your child to may not be free of charge and that you are responsible for any payment for those services.
6. It is your responsibility to be familiar with the service limitations of the Resource Specialist.
RS services are preventative and do not include the following:
I understand and agree to the Rights & Responsibilities, as described above: