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New Directions. Brighter Futures.


Community Youth Services


Effective Date: September 23, 2013

This notice describes how information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.  If you have any questions, please ask your Case Manager, Therapist or other direct service staff that you are working with at CYS.

This notice applies to the information and records we have about you, your health, health status, and the health care and services you receive from Community Youth Services.  Your information may include information created and received by CYS, may be in the form of written or electronic records or spoken words, and may include information about your health history and health status.

We are required by law to give you this notice.  It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure and how you can get access to this information.


I. Our commitment to protecting information about you
II. How we may use and disclose protected health information about you
III. Your rights regarding protected health and other information about you
IV. Requests to review confidential participant information
  • Distributing Participant Information
  • Process for Participant File Review
V. Making a complaint
VI. Privacy official contact information



A federal regulation, known as the “HIPAA Privacy Rule,” requires that certain health care providers deliver detailed notice in writing of their privacy practices. The terms “We” and “Our” refer to Community Youth Services and the term “you” and “your” and “participant” refer to you as a specific Community Youth Services program participant.  Community Youth Services provides certain aspects of mental health counseling services and therapeutic residential care that are covered under the HIPAA Privacy Rule.  The term “information” refers to Protected Health Information and other information relevant to a specific participant.

It is the policy of CYS to take a protective role regarding the disclosure of information about our program participants.  While not all of the services we provide fall under the HIPAA regulations, CYS provides privacy protection for all participants, as required by federal and state laws, professional standards and ethics and contractual agreements.

Many programs at CYS work collaboratively with multiple professionals to coordinate services, information may be shared on a need-to-know basis to enhance services and make them more efficient.  In the event that a participant is functionally illiterate or are particularly vulnerable as a result of mental disability, CYS will exercise special care in helping them understand the release of information process.  In addition, CYS may include their parent or guardian or other adult acting on their behalf.

In addition to the Case Managers, therapists (or Mental Health Professionals) and other staff whom it employs, Community Youth Services contracts with medical professionals, psychiatrists, social service professionals and other mental health professionals who provide consultation services as well as individual and family services at their private offices or in the community.

The HIPAA Privacy Rule requires that we protect the privacy of health information that identifies a participant, or where there is a reasonable basis to believe the information can be used to identify a participant. This information is called “protected health information” or “PHI.” This Notice describes your rights as a health plan participant and our obligations regarding the use and disclosure of PHI.

We are required by law to:

  • Provide you with a copy of this Notice of Privacy Practices
  • Maintain the privacy of PHI about you
  • Give you this Notice of our legal duties and privacy practices with respect to PHI
  • Comply with the terms of our Notice of Privacy Practices that is currently in effect.

We reserve the right to make changes to this Notice and to make such changes effective for all PHI we may already have about you. If and when a significant change is made to this Notice, we will make the revised Notice available upon request as of the effective date of the revision. We also will promptly make the revised Notice available at our service delivery sites and by posting prominently in such sites following the effective date of any revision.



Generally, the programs, including those providing mental health or therapeutic residential care may not say to a person outside the program that a person attends or participates in the program, or disclose any information identifying a participant without the participant’s consent.  However, there are many legally recognized people and situations where information may be disclosed without the participant’s authorization, including, but not limited to:

  • For Treatment and Services ProvidedWe may use health information about you to provide you with medical treatment or services.  We may disclose health information about you to doctors, nurses, technicians, staff or other personnel who are involved in taking care of you and your health.

    Different personnel in our organization may share information about you and disclose information to people who do not work for CYS in order to coordinate or manage your care and/or services. For example, we may use or disclose your information when you need a prescription or other health care services.  In addition, we may use and disclose information about you when referring you to another CYS program or provider for services and/or treatment.  Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.  We will request your permission before sharing health information with your family or friends unless you are unable to give permission to such disclosures due to your health condition.

  • For payment.  We may use and disclose health information about you so that the treatment and services you receive at CYS may be billed to and payment may be collected from you, an insurance company or a third party. We may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us.

    For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will pay for the treatment.

  • For Business Operations and Activities.  We may use and disclose health information about you in order to run CYS and make sure that you and our other participants receive quality care and services. 

    For example, we may use and disclose your health information in reviewing and improving the quality, efficiency and cost of our operations. This may include reviews and audits by licensing and accreditation agencies, our quality assurance process, a peer review, audits, administrative, financial, educational, and planning processes and research services on behalf of CYS.

    We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you.  Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.

  • Fundraising.  We may contact you to ask for your help with different fundraising, community outreach and education campaigns.

    Please notify us if you do not wish to be contacted during fundraising, community outreach and education campaigns.  If you advise us in writing (at the physical or email address listed at the top of this Notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.


We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

  • State Department of Social and Health Services. For families who are involved in the child welfare system or receiving services from DSHS, their state social worker and/or Guardian Ad Litem are authorized to obtain and release appropriate information on their behalf.  Foster parents have access to all relevant and legally permissible information concerning the child to be placed or currently in their care.
  • To Avert a Serious Threat to Health or Safety.  We may use and disclose health 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.  This includes disclosure to medical personnel in a medical emergency.
  • Duty to Warn. The participant’s right to privacy in confidentiality is over-shadowed if a CYS staff or provider has accurate, foreseeable knowledge that harm could come to a third party because of the participant. A warning could be given to either the potential victim or the police. When CYS’s need to protect staff, the participant or the other people from the behavior of the participant outweighs the participant’s right to privacy.
  • Required By Law.  We will disclose health information about you when required to do so by federal, state or local law.
  • Research.  We may use and disclose health information about you for research projects that are subject to a special approval process.  We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in services provided to you.
  • Military, Veterans, National Security and Intelligence.  If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you.  We may also release information about foreign military personnel to the appropriate foreign military authority.
  • Specialized government functions, disaster relief efforts and/or national security. (For example, the Red Cross, use of a participant’s social security number to confirm male applicants to the CareerTrek program have registered for Selective Service, as required by law, etc.) may require the release of your information.
  • Workers’ Compensation.  We may release health information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.
  • Public Health Risks.  We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
  • Health Oversight Activities.  We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes.  These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
  • Court Order & Legal Actions.  We may use or disclose information about you when required by a court order, administrative agency order, subpoenas, discovery requests, or other lawful press, subject to all applicable legal requirements.
  • Department of Corrections. We may be required to disclose your information to the Department of Corrections, if you are under their supervision.
  •  Law Enforcement.  We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

    We may disclose information to police, as it relates to their responsibilities in a legal case, to report domestic violence or child abuse and/or neglect and to Child Protective Services (CPS) for investigation or reporting a clear threat of harm or allegation of child abuse and/or neglect.

  • Coroners, Medical Examiners and Funeral Directors.  We may release health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.

    In the event of your death, upon receipt of a copy of death certificate, information may be released to the surviving family members in order of consent per Washington “Hierarchy in Decision Making” Law.

    • Guardian/Parent,
    • Durable Power of Attorney (specifically regarding healthcare),
    • Spouse (current only),
    • Children (age 18 and older) and in unanimous agreement if more than one,
    • Adult siblings, and in unanimous agreement if more than one.
  • Information Not Personally Identifiable.  We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
  • Family and Friends.  Parents and guardians can request information about their children, under age 18, unless the youth has restricted their parent’s access and CYS has approved this restriction, and as permitted by law. 
  • We may disclose health information about you to your family members, foster parents, natural supports and other individuals with whom the participant is known to have a close personal relationship if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object.

    In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest.  In that situation, we will disclose only health information relevant to the person’s involvement in your care.  For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis.  We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or X-rays.


We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific written Authorization.   Examples of disclosures requiring your authorization include disclosures to your partner, your spouse, your children and your legal counsel.

Disclosures that are incidental to permitted or required uses or disclosers under HIPAA are permissible so long as we implement safeguards to avoid such disclosures and limit the PHI exposed through these incidental disclosures.

We also will not use or disclose your health information for the following purposes without your specific, written Authorization:

  • For our marketing purposes.  This does not include face-to-face communication about products or services that may be of benefit to you and about prescriptions you have already been prescribed.
  • For the purpose of selling your health information.  We may receive payment for sharing your information for, as an example, public health purposes, research, and releases to you or others you authorize a release to as long as payment is reasonable and related to the cost of providing your health information.
  • Any disclosure of your psychotherapy notes.  These are the notes that your behavioral health provider maintains that record your appointments with your provider and are not stored with your medical record.

If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time.  If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

In some instances, we may need specific, written authorization from you in order to disclose certain types of specially-protected information such as HIV, substance abuse, mental health, and genetic testing information for purposes such as treatment, payment and healthcare operations.  


Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster.  We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

Other Uses and Disclosures: All other uses and disclosures of your PHI will be made only with your written permission (an “authorization”). If you have given us written permission to use or disclose your PHI, you may later take back (“revoke”) your written permission at any time. If you revoke your permission, it will apply only after we receive your written revocation and will not apply to any situation in which we have already acted based on your permission.



Under federal law, you have rights regarding PHI about you. You can exercise any of the specific rights identified below for PHI about you that we hold by using the appropriate form available from our Privacy Official, whose contact information is listed below.

The following information will not be shared with participants or collateral contacts:

  • When it is reasonably believed the information might cause harm to the participant or to anyone else. 
  • When the release requests information received from another entity.  That entity must be contacted directly to receive that information.
  • When a participant has explicitly requested specific information be held confidential, or requests a specific person or system be denied information on the participant.  CYS may not always agree to comply with this request and will inform the participant if the request is denied.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care or the payment for it, 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, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information.

We are required to agree to your request if you pay for the treatment, services, supplies and prescriptions “out of pocket” and you request the information not be communicated to your health plan for payment or health care operations purposes.  There may be instances where we are required to release this information if required by law.

To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information to your Case Manager, Therapist or other direct service staff that you are working with at CYS.

Right to Receive Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information and/or Confidential Communication to [your Case Manager, Therapist or other direct service staff that you are working with at CYS.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.

Right to allow others to access your PHI:  You or your parent (in certain situations described above) have the right to release your confidential information to other service providers and family members by submitting a request to release information in writing. 

Right to Inspect and Copy:  You have the right to inspect and copy your case file and health information, such as medical and billing records, that we keep and use to make decisions about your care.  You must submit a written request to your Case Manager, Therapist or other direct service staff that you are working with at CYS in order to inspect and/or copy records of your health information.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. 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.  A modified request may include requesting a summary of your medical record.

If you request to view a copy of your health information, we will not charge you for inspecting your health information.  If you wish to inspect your health information, please submit your request in writing to Case Manager, Therapist or other direct service staff that you are working with at CYS. 

You have the right to request a copy of your health information in electronic form if we store your health information electronically.

We may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances.  If you are denied copies of or access to, health information that we keep about you, you may ask that our denial be reviewed.  If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial.  The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend: If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment as long as the information is kept by CYS.

To request an amendment, complete and submit a medical record amendment/correction form to Case Manager, Therapist or other direct service staff that you are working with at CYS.

We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request.  In addition, we may deny or partially deny your request if you ask us to amend information that:

  • We did not create, unless the person or entity that created the information is no longer available to make the amendment
  • Is not part of the health information that we keep
  • You would not be permitted to inspect and copy
  • Is accurate and complete

Right to Receive an Accounting of Disclosures: You have the right to request an “accounting of disclosures.”  This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, when specifically authorized by you and a limited number of special circumstances involving national security, correctional institutions and law enforcement. 

If we deny or partially deny your request for amendment, you have the right to submit a rebuttal and request the rebuttal be made a part of your medical record. Your rebuttal needs to be three of pages in length or less and we have the right to file a rebuttal responding to yours in your medical record.  You also have the right to request that all documents associated with the amendment request (including rebuttal) be transmitted to any other party any time that portion of the medical record is disclosed.

To obtain this list, you must submit your request in writing to Case Manager, Therapist or other direct service staff that you are working with at CYS. It must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). 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 a Paper Copy of this Notice: You have a right to request and receive a paper copy of this Notice at any time.

We reserve the right to change this notice, and 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 the current notice at our location(s) with its effective date in the top right hand corner.  You are entitled to a copy of the notice currently in effect.

We will inform you of any significant changes to this Notice.  This may be through our newsletter, a sign prominently posted at our location(s), a notice posted on our web site or other means of communication.

We will inform you if there is a breach of your unsecured health information.



Current and former participants will have access to their files, when legally mandated.  Any request from a previous or current participant to review a case file or release participant information must be received in writing.  To be valid, the authorization may be a letter, another entity’s form, or CYS’s Consent for Release of Confidential Information Form.  Requests for information must include:

  • Signature and date by the participant, or parent / legal guardian if the participant is unable to provide it.
  • Statement indicating a 90 day limitation of use for one-time releases (unless specified otherwise when the release is required by law for ongoing services by a contracted or cooperating service provider)
  • Specifically names the organization and the primary care provider in possession of the information, who will release it. 
  • Lists exactly what information is to be released, the purpose of the release and who will receive the information
  • States that the participant has the right to revoke / withdraw the release
  • Representatives signing have designated their relationship with the participant. 

CYS will respond to a participant’s written authorization as promptly as possible.  CYS will respond within:

  • Five (5) working days for Participant requests to review their file
  • Fifteen (15) working days to provide document copies to collateral contacts. 
  • Five (5) days when information can be provided by phone.

If unusual circumstances delay CYS’s response, the participant must be informed in writing before the mandatory response period ends with reasons for the delay and when the information will be provided. 

Distributing Participant Information:

  • CYS will fax or mail requested information.  If faxed, the receiving party must have a fax machine that is in a secure environment and directly to the person requesting the information.  A cover sheet stating that confidential information is being faxed must be included with the documents. 
  • Original Authorizations to Release Information will be retained in the participant record for the life of the file.  On the bottom of the form, the date, a description of the pages sent, total number of pages and who released the information will be included.
  • CYS may charge a reasonable fee for release of copies, not to exceed the actual overhead copying expenses.  Participants will be informed of any charges prior to beginning the copy process.  For closed records maintained at off-site secure storage, fees will includes the cost of copying, retrieving and re-filing the record.  Copies will be held until receipt of payment. 
  • Out of Home Care programs may provide a courtesy copy of a person’s medical information, prescriptions and other health records of the participant’s record / family on discharge from the program free of charge. 
  • CYS staff may release information verbally, with written authorization from the participant.  This will be documented in a case file.  If there is currently not a case file, such as in outreach services, a case file will be created.

Process for Participant File Review: 

  • Any case file review must be done in the presence of the Community Youth Services staff member who is familiar with the case. 
  • If a program participant wants to insert information into the file to clarify information or challenge information, he/she may do so.  The program participant’s statement will be entered and clearly identified as such.  If staff chooses to add a statement or comment regarding the client's statement, they may do so, but only with the knowledge of the client.
  • By law, any information in the file that may be psychologically damaging to either the client or parent may be withheld.  Likewise if another agency has provided information, it will be withheld.  The Program Director will review and approve any information that will be withheld.  This will be documented in the case file.
  • In addition, information regarding other individuals, including family members may be withheld.
  • The participant may enlist a qualified master’s level professional to review their record on their behalf, provided the professional signs a statement that information determined to be harmful will be withheld. 


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. Threats to commit a crime also are not protected.

If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint with our office, please contact our Privacy Official. We will not retaliate or take action against you for filing a complaint. You may also file a complaint directly with the Secretary of the United States Department of Health and Human Services Office for Civil rights by sending a letter to 200 Independence Ave SW, Washington, DC 20201 or 877-696-6775.



If you have questions, you may contact our Privacy Official at the following addresses and phone numbers:

Privacy Official: Amanda Phinney
Community Youth Services
711 State Ave. NE, 3rd floor
Olympia, WA 98506

Phone: (360) 918-7815


This updated notice was published and first became effective on September 23, 2013.


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