I wish to receive services provided by Allies In Hope. through its staff of professionals and its trained volunteers. I understand that key activities of the staff and volunteers of Allies In Hope. include assessing my eligibility and needs; providing me with requested services; networking with other agencies, and ensuring the coordination, monitoring, and quality of services received. I understand that Allies In Hope. staff and volunteers may discuss information about me for the accomplishment of these activities.
I understand that my identity and my participation with Allies In Hope. and the approved
agency database systems are confidential. I understand that no information or records associated with my case
will be knowingly released to anyone or any agency without my informed written consent, or a subpoena, court
order or legal statute. I am giving this consent of my own free will. This consent will remain in effect until I provide a written statement revoking my consent. Furthermore, this consent shall remain valid for two (2) years and expire two years from today's date.

 

 

Allies In Hope offers a variety of screening tests for communicable diseases including the HIV antibody test and the Rapid Plasma Reagin (RPR) test for syphilis.
The HIV (Human Immunodeficiency Virus) antibody test detects antibodies to HIV and not the virus itself. Antibodies are created as a natural response to infection. A positive antibody test indicates that a person is infected with HIV and is capable of transmitting the virus to others. A positive test result does not indicate that a person has or ever will have AIDS. Persons who are recently infected with HIV may test negative for HIV antibodies. Therefore, it may be necessary to repeat the test at a later date. Allies In Hope offers
two HIV testing methods: the blood test and the rapid test utilizing a finger stick or oral swab specimen collection. The Rapid Plasma Reagin (RPR) test is for the serologic detection of syphilis. A positive test indicates that a person currently has syphilis or has had syphilis in the past. A medical professional will determine, by reading the titer and obtaining a treatment history, if the RPRpositive person requires treatment. Persons who are recently infected with syphilis may test RPR negative. For this reason, it may be necessary to repeat the test at a later date. If you should test positive for syphilis, a Public Health Liaison may contact you to discuss
treatment options and to interview you to determine if you have any sex partners that need to be notified, tested and treated. Confidential Testing means that your test result will have your name on it. Under the laws of the State of Texas, persons testing positive for HIV and syphilis will have their name and identifying information (address, birthdate, sex, and race/ethnicity) reported to the Houston Department of Health and Human Services and/or the Texas Department of State Health Services. This information is not public information and violations of confidentiality are punishable by law. Other than the legal requirement to report persons testing
positive for HIV or syphilis to the local health department, confidential results cannot be released to anyone without your written consent. You must return in person and present your return receipt in order to obtain your results. By signing below, you acknowledge that AIDS Foundation Houston has provided you with its Notice of Privacy Practices, which explains how your health information will be handled in various situations. I am also providing Allies In Hope with permission to contact me by means of any of the information provided below.The counselor has discussed testing options with me, and I fully and voluntarily chose to provide my name and identifying information for the indicated confidential test(s). I understand and agree that my identifying information may be reported to the Health Department if I test positive for HIV and syphilis. I therefore initial the test I am requesting and sign this form indicating that I agree to have my blood drawn (and/or to have an oral specimen or a whole blood specimen with a fingerstick for the rapid HIV test) and to have it tested for the following sexual health tests.

 

 

Clients are to be given a copy of this document after signatures are obtained
As a client of Allies In Hope, you have the following rights:
I. You have the right to impartial access to services/treatment regardless of race, religion, sex, ethnicity, sexual/affection
orientation, gender identity, age or handicap.
II. You have the right to considerate and respectful care.
III. You have the right to be free from mistreatment, abuse, neglect and exploitation.
IV. You have the right to review your file periodically.
V. You have the right to communicate about your care and services in a language and format that is understandable to you.
VI. You have the right to privacy. Information about your care or your service needs may not be given directly or by reference to the public or anyone outside the Agency without written consent as governed by local, State and Federal Law. (Exceptions: subpoenas from a court of law, or when there is reasonable concern that harm may come to you or others).
VII. You have the right to be informed of all rules and regulations of the Agency related to your participation in services (including costs, expectations, and duration of services).
VIII. You have the right to initiate a complaint regarding your care and to be informed of the Agency grievance procedure.
IX. You have the right to withdraw your consent for services and to make your choices without pressure.

 

As a client of Allies In Hope, you have the following responsibilities:
I. You have the responsibility to participate in the development and implementation of your service plan to the extent that you are able.
II. You have the responsibility to inform your Allies In Hope when you do not understand instructions or
information that you receive.
III. You have the responsibility to keep your scheduled appointments with your Allies In Hope service provider and other outside service providers, and to notify them when you need to cancel or reschedule.
IV. You have the responsibility to follow through with those activities that you agree to perform in regards to your service plan and to notify your Allies In Hope service provider when you are unable to do so.
V. You have the responsibility to notify your Allies In Hope service provider of any changes of information about you, including, but not limited to: address, phone number, income status,
VI. You have the responsibility to notify your Allies In Hope service provider of services that you have obtained independently from Allies In Hope services.
VII. You have the responsibility to communicate your needs to your Allies In Hope service provider as quickly as possible,
understanding that they may not be able to satisfy “last minute” requests.
VIII. You have the responsibility to conduct yourself appropriately when interacting with persons involved in providing your services. Inappropriate behavior includes intoxication, threats, harassment and physical abuse or abusive/violent language. Failure to uphold your responsibilities could result in the suspension of services for a determined period of time including
permanent suspension.

 

 

Allies In Hope strives to provide quality services to all clients and welcomes input
regarding services. Allies In Hope resolves client complaints in the following manner:

 

Allies In Hope CLIENT COMPLAINT POLICY:
1. All procedures regarding the complaint and grievance resolution will remain confidential unless the client
voluntarily signs a release of information to a third party.
2. All proceedings during resolution of the grievance will be documented and such documentation will be
available to all involved parties within the bounds of appropriate confidentiality protections.
3. All client complaints will be resolved in writing within three (3) business days of the time the written
complaint is received in writing at the Allies In Hope main office except as stated below.

 

PROCEDURE FOR FILING A COMPLAINT:
1. If a client has a complaint, he/she must first bring the grievance to the specific staff person(s) involved in the
complaint. If the client is not satisfied with the resolution, he/she must submit the complaint in writing to the
Program Coordinator who will issue a written resolution within three (3) business days.
2. If the client is not satisfied with the resolution to the written complaint, or if the complaint involves the
Program Coordinator, he/she must submit an appeal to the decision in writing to the Program Manager within
three (3) business days of the initial decision. The Program Manager will review the appeal and render a
written decision within three (3) business days.
3. If the client is not satisfied with the resolution to the written complaint, or if the complaint involves the
Program Manager, he/she must submit an appeal to the decision in writing to the Vice President of Client
Services within three (3) business days of the initial decision. The Vice President of Client Services will
review the appeal and render a written decision within three (3) business days.
4. If the client is not satisfied with the resolution of the complaint, he/she must appeal in writing to the Chief
Operating Officer (COO) within three (3) business days of the appeal decision. The COO will review the
complaint and issue a decision in writing to the client within three (3) business days.
5. If the client is not satisfied with the resolution of the complaint, he/she may appeal in writing to the Grant
Funding Source within three (3) business days of the decision of the COO. The decision of the Grant Funding
Source is final. Contacting the funding source can be done at any time during the grievance process.

 

1. During the appeals process, the client may request a face-to-face hearing with the appropriate staff member
reviewing the complaint. If a hearing is requested, the client waives his/her right to resolution within three (3)
business days.
2. The client may choose at his/her own expense to retain counsel during any stage of the appeals process. The
decision to retain counsel, however, does not obligate Allies In Hope to extend the appeals process beyond the time
frame stated above.
3. The client and/or his/her representative may examine any documentary evidence presented during any hearing.

 

 

By my signature below I fully release and hold the entity(ies) administering the funding for the services
provided through Allies In Hope, their Officers, Directors, Board Members, employees and
agents (i.e.: volunteers, students) harmless from any and all damages, losses, liabilities (joint or several),
payments, obligations, penalties, claims, litigation, demands, defenses, judgments, suits, proceedings, costs,
disbursements or expenses (including without limitation, fees, disbursements and expenses of attorneys, and
other professional advisors and of expert witnesses and costs of investigation and preparation) of any kind or
nature whatsoever resulting from, relating to or arising out of my receipt of services.

 

I. POLICY:
A. General Rule. ALLIES IN HOPE recognizes a patient’s right to receive adequate notice of the uses and disclosures of Protected Health Information that may be made by ALLIES IN HOPE, and of the patient’s rights and ALLIES IN HOPE’s legal duties with respect to Protected Health Information.
B. Content of Notice. ALLIES IN HOPE provides each patient with a notice of ALLIES IN HOPE’s privacy practices that is written in plain language and that contains the elements required by the Privacy Standards if ALLIES IN HOPE has a direct treatment relationship with the patient. The Privacy Officer maintains the current version of ALLIES IN HOPE’s Notice of Privacy Practices (the “Notice”) in the Privacy Office.
C. Acknowledgment of Receipt. ALLIES IN HOPE uses good faith effort to obtain a written acknowledgment by the patient of receipt of the Notice. If ALLIES IN HOPE obtains written acknowledgment of receipt, ALLIES IN HOPE maintains documentation of the acknowledgment for the documentation period specified below. If despite good faith efforts, ALLIES IN HOPE is unable to obtain a written acknowledgment of receipt, then ALLIES IN HOPE will document its efforts and the reason(s) why the written acknowledgment of receipt could not be obtained.
D. Revisions to the Notice. ALLIES IN HOPE will promptly revise and distribute its Notice whenever there is a material change to the uses or disclosures, the individual’s rights, ALLIES IN HOPE’s legal duties, or other privacy practices stated in the Notice. If the Notice permits ALLIES IN HOPE to make changes to its terms at any time, a material change to the Notice may be implemented at any time. If the Notice does not permit such changes at any time, a material change to the Notice will not be implemented prior to the effective date of the Notice in which such material change is reflected.
E. Provision of Notice.

 

1. ALLIES IN HOPE provides the Notice electronically or in person no later than the date of the first service delivery, including service delivered electronically.
2. ALLIES IN HOPE makes the Notice available at its offices for individuals to take with them upon request.

3. ALLIES IN HOPE posts the Notice in a clear and prominent location where it is reasonable to expect individuals seeking service from ALLIES IN HOPE to be able to read the Notice.

 

B. Electronic Notice.
1. ALLIES IN HOPE prominently posts its Notice on its website and makes the Notice available electronically through the website. ALLIES IN HOPE should coordinate the Notice language with ALLIES IN HOPE’s website privacy policy and terms of use.
2. ALLIES IN HOPE provides the Notice to a patient by e-mail, if the patient agrees to electronic notice and such agreement has not been withdrawn. ALLIES IN HOPE retains conformation of the transmission of the e-mail. If ALLIES IN HOPE knows that the e-mail transmission has failed, a paper copy of the Notice will be provided to the patient.
3. If the first service delivery to a patient is delivered electronically, ALLIES IN HOPE must provide electronic notice automatically and contemporaneously in response to the patient’s first request for service.
4. The patient who is the recipient of electronic notice may obtain a paper copy of the Notice from ALLIES IN HOPE upon request.
C. Documentation. ALLIES IN HOPE documents compliance with the Notice requirements by retaining copies of the Notices it issues and any written acknowledgments of receipt of the Notice (or documentation of good faith efforts to obtain such acknowledgment) for a period of six years from the date of their creation, or the date when such Notice last was in effect, whichever is later, in accordance with Policy (HIPAA Document Retention)

 

 

Your Information. Your Rights. Our Responsibilities.
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.

ALLIES IN HOPE recognizes a patient’s right to receive adequate notice of the uses and disclosures of Protected Health Information that may be made by ALLIES IN HOPE, and of the patient’s rights and ALLIES IN HOPE’s legal duties with respect to Protected Health Information. ALLIES IN HOPE provides each patient with a notice of ALLIES IN HOPE’s privacy practices that is written in plain language and that contains the elements required by the HIPAA Privacy Standards
Your Rights

 

You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
We may use and share your information to:
• Treat you
• Run our organization
• Bill for your services if applicable
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Rights
When it comes to your health 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 medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.• 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.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time and tell us in writing.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.