Privacy Policy

1. SOZO Client Privacy, Confidentiality, Legal Issues & Release of Information Policy

In the course of delivering its services and programs, SOZO collects personal information from its clients. Personal information means any information that could be used on its own, or with other information, to establish the identity of a client, the client’s service provider or the client’s substitute decision maker. Personal information also includes any other information about a client including information that is contained in a client record.

SOZO collects, uses and shares client’s personal information for the following purposes:

1. Providing quality programs and services to clients
2. Providing information to other people or organizations with client consent (for example, making a referral for service)
3. Contacting clients, donors and members to evaluate SOZO service and work
4. Conducting research to understand the kinds of issues our clients are facing
5. Contacting individuals about our fundraising and membership activities
6. Reviewing client files to ensure high quality of service and documentation
7. SOZO may also collect, use and share personal information with consent or as permitted or required by law.

SOZO is committed to protecting the privacy of its clients and ensuring that:

1. the personal information it receives from clients is kept safe, secure, confidential, accurate and up to date
2. clients understand why their personal information is collected by SOZO
3.  SOZO obtains client consent before collecting, using, sharing or releasing client information, except as set out in this policy or permitted or required by law
4. only the personal information necessary for the purposes listed above is collected from clients, unless otherwise consented to by the client or permitted or required by law
5. access to client information is limited to the SOZO employees, volunteers and students involved in delivering services to clients
6. any external agents to whom SOZO releases information have a need to know and only use and disclose client information for the purposes for which it was originally provided
7. clients are able to withdraw their consent at any time to the collection, use and disclosure of their personal information
8. clients have access to their record, except where SOZO is entitled to refuse an access request, and are able to copy or correct their record and ask questions about SOZO privacy policies and procedures
9. complaints about SOZO privacy policies and procedures are handled efficiently and effectively
10. all legal and regulatory requirements regarding client information are met and maintained

1. SCOPE

This policy applies to all SOZO employees, students and volunteers.

• PROCEDURES

1. Obtaining Consent

1. As SOZO services often involve collaboration and consultation among employees, SOZO employees will discuss the following with new clients:
2. the nature and extent of consultation and collaboration in the SOZO program or service which the new client is accessing
3. the personal information that SOZO may collect

• the purposes for which SOZO collects, uses and shares personal information, as listed above

1. Client’s rights and responsibilities including rights related to keeping client’s personal information private will be reviewed with all new clients at their first appointment following intake
2. Clients will be asked to use a form indicating that the organization’s privacy policies have been discussed and that the client consents to the collection use and sharing of personal information for the purposes listed in this policy.
3. The signed forms will be maintained by the program (e.g., in the client’s paper record, filed centrally within the program). A note will be made in the client’s electronic record that the form has been signed.
4. In cases where it is not possible or practicable to obtain the client’s written acknowledgment (e.g., telephone only service), verbal acknowledgment that the organization’s privacy practices have been explained to, and accepted by, the client will be recorded in an activity note in the client’s record.
5. Consent will be that of the individual and must be knowledgeable, relate to the personal information and not be obtained through deception or coercion. A consent to the collection, use or sharing of personal health information about an individual is knowledgeable if it is reasonable in the circumstances to believe that the individual knows:
   1. the purposes of the collection, use and/or disclosure, as the case may be; and
   2. that the individual may give or withhold consent.
6. In the event that employees are concerned that a client does not have the capacity to consent to the collection, use and disclosure of his or her personal information, employees should:
7. Consider whether the client understands the decision they are being asked to make
8. Question whether the person understands the reasonably foreseeable consequences of the decision or lack of decision

• Consult with their supervisor

1. Client Withholding, Limiting or Withdrawing Consent

1. Clients have the right to stipulate who will have access to their personal information. This means that they can withhold, limit or withdraw their consent to the collection, use or disclosure of personal information. The request may cover all or a specific part of a client’s record. When this happens, staff will implement the following “lock-box” procedure.
2. Electronic records: The SOZO employee receiving the client’s request to withhold, limit or withdraw their consent will:
   1. Record the verbal instructions by the client in an activity note in the client’s electronic record
   2. Scan any written instructions by the client into the client’s electronic record
3. Paper records – If the client also has a paper file:
   1. The client’s file (either in whole or in part depending on the client’s instructions) to which access is to be limited will be placed inside an envelope that will be sealed with the instructions from the client stapled to the outside of the file.
   2. If the client’s request is to withdraw consent, the file will be safeguarded by SOZO Privacy Officer.

• If the client’s request is to withhold or limit consent, the supervisor responsible for the program will determine how best to comply with the client’s request.

1. In cases where the withholding, limiting or withdrawal of consent will limit or prevent SOZO from continuing to deliver services, employees will discuss with the client the consequences of their withholding, limiting or withdrawal of consent.

1. Disclosure without Consent Including Responding to Summons/Subpoenas/Court Orders and Requests from Police

1. SOZO will not disclose the personal information of clients without their consent, except where:
   1. It is believed the client or someone else is in imminent danger of serious physical harm (see Duty to Warn policy)
   2. A child under the age of 18 is at risk of or has been abused or neglected (see Child Abuse Reporting and Documentation policy)

• SOZO is subpoenaed or is otherwise served with a court order, summons, warrant or a similar requirement issued by a person who has jurisdiction to compel the production of information in a proceeding

1. It is otherwise permitted or required by law.
2. If SOZO employee, student or volunteer is served with a warrant, summons, subpoena, order or similar requirement issued in a proceeding, the individual must immediately notify their supervisor, who will provide advice and direction as to how to respond. SOZO employees, students or volunteers should follow the same procedure in response to requests by police officers for client information.

1. In general, where an order, summons, warrant, subpoena or other requirement has been served on SOZO, SOZO will:
   1. Make every attempt to respond in a way that is respectful of the order or other requirement, while at the same time taking steps to preserve the client’s right to confidentiality. Contact Executive Director, or designee immediately. Executive Director, or designee will contact legal counsel in matters concerning legal matters as needs arise.
   2. A subpoena is an order directing the recipient to appear and testify at a specific time and place. A subpoena duces tecum requires the receipt to produce certain documents listed in the subpoena on the date and time designated in the subpoena.  Subpoenas will be reviewed by Compliance Officer and Clinical Director for further action to be taken.  If subpoena is legal, staff will make a copy of the file and deliver the documents to the court or other proceeding in a sealed enveloped marked “private and confidential.”

• If police arrive with a search warrant of SOZO property staff will take every step to protect all clients’ confidentiality and privacy. All clients will be informed police have arrived with a search warrant of the property and they have the option of leaving the area or going into their respectively rooms.  Staff will not identify any client during search of property.  Staff will respectfully ask client in question if present to identify themselves to police and attempt to handle this matter in a private setting such as the counselors’ building away from other clients. If client refuses staff will continue following protocol of allowing search after all clients have been notified police will be allowed to search property.  This only if correct search warrant has been confirmed.  

1. All employees are to be aware of procedures involving the attempt by any person to execute an arrest warrant on SOZO Recovery Center Inc. premises. Although employees will not hinder or resist any officer attempting to serve an arrest warrant, they will also offer no assistance in locating said client. Every effort should be made to convince arresting officers to obtain a proper court order as to allow greater cooperation by the program.
2. SOZO is subject to various federal, state, and local regulatory agencies, law enforcement departments and governmental agencies. If an individual for a governmental agency appears, immediately contact Executive Director, or designee.  SOZO personnel are not to release client information, formally or informally, without contacting the Executive Director, or designee.

1. Where SOZO discloses personal information without the client’s consent, the client will be notified of such disclosure as soon as reasonable, practical, safe and/or legally possible in the circumstances.

1. Release of Information with Client Consent

1. 1. Subject to Section 4, personal information, whether all or part of a client record, will not be released to third parties without the written consent of the client or the client’s substitute decision maker, where applicable. Clients are required to complete the SOZO Authorization to Request or Release Information Form, depending on the nature of the request. Consents provided on these forms are valid for one year, unless otherwise limited or withdrawn by the client in advance of that date. SOZO may disclose a client’s personal information, provided that the disclosure, to the best of SOZO knowledge, is for a lawful purpose.
   2. Reports from third parties contained in a client record may not be released without the written consent of the third party. Clients will be encouraged to pursue access to this information directly with the third party.
   3. In exceptional circumstances, where written consent is not possible, the oral consent of the client to the release of personal information will be accepted and will be recorded in the client’s file.
   4. In response to requests to release information to third parties, the SOZO service provider will ensure that the client understands the purpose for which the information is being released and to whom the information is being released. The SOZO service provider will also explain that SOZO cannot guarantee the confidentiality of the information once it has been released.

1. Safeguarding of Personal Information

1. 1. Client information stored electronically is protected by password. Access to the SOZO electronic database is limited on a need to know basis for added security.
   2. Client information collected in hard copy form is stored in locked cabinets accessible only by the counselors or other SOZO employees, students and volunteers providing service to the client, and the relevant managers.
   3. Access to client information will be limited to those who need to know the information for the purposes set out in the client’s consent or as otherwise permitted or required by law.
   4. SOZO employees will never leave client personal information, in paper or electronic form, unattended or exposed to anyone other than the client.
   5. SOZO will not send confidential personal information to clients by email without the client’s prior consent. Personal information sent to clients or about clients will employ secure email. (Note that secure e-mail ensures messages are encrypted.)
   6. SOZO requires external agents, such as third-party auditors, to maintain the confidentiality of client information and to refrain from using client information for any purpose other than the purposes for which consent was provided by the client. Where appropriate and necessary, SOZO will obtain the consent of the client to disclosure of information to external agents. (External agents are persons or companies with which SOZO has contracts and that may come into contact with personal information.)
   7. When disposal is permitted or required, records of client personal information will be disposed of in a secure manner such that reconstruction of the records is not reasonably foreseeable in the circumstances.

1. Notice to Clients of Theft, Loss, Unauthorized Access, Use or Disclosure of Personal Information

1. Employees are required to report to their supervisor and to the SOZO Privacy Officer any theft, loss, unauthorized access, use or disclosure of personal information of SOZO clients. In programs where funders require it, managers will file a serious occurrence report in this situation.
2. In the event of such theft, loss, unauthorized access, use or disclosure of personal information of a SOZO client, SOZO will notify the client as soon as possible.
3. Oral contact with the clients will be logged in the client record and will be followed up by a letter, which will be included in the client record.
4. In the case of former clients, contact will be made orally, if possible, and also in writing, at the last known address for the client recorded in SOZO database.

1. Client Access to and Correction of Personal Information

1. Clients wishing to review their records should contact the SOZO service provider, relevant manager or Privacy Officer.
2. Within 30 days of any such written request, an appointment will be made for the client to review his/her personal information in a confidential manner on SOZO premises, in the presence of a SOZO employee, unless SOZO is entitled to refuse the request, in which case written notice will be given. Clients may bring a support person to this appointment if they wish. Up to 60 days may be required in the case of complex searches for records. In exceptional circumstances (e.g., a client is unable to come to the SOZO office due to health issues), a copy of the record may be sent to the individual with consent.
3. SOZO is required to retain client personal information that is the subject of a request for access for as long as necessary to allow the client to exhaust any recourse that he or she may have with respect to the request. This may require SOZO to maintain the record for longer than the typical client record retention period.
4. Clients who wish an explanation of their records may contact their SOZO service provider, the relevant program manager or the SOZO Privacy Officer.
5. Clients will not be permitted to access third party records without the request for consent of the third party. In such cases, the SOZO service provider will direct the client to obtain the requested information directly from the third party.
6. Clients requesting to correct information in their file shall provide the correction in writing to SOZO. The written correction will be included in the client’s record and, within three weeks of receipt, SOZO will notify the client of its response to the correction.

1. Appointment of Privacy Officer

1. The Privacy for SOZO is the Clinical Director.
2. The name and contact information for the Privacy Officer is available in the Client Rights and Responsibilities Statement and in the SOZO Employees Directory.
3. The duties of the Privacy Officer include:
   1. Maintaining knowledge of privacy legislation and regulations
   2. Ensuring that all employees and volunteers have training on the privacy policy

• Monitoring employee compliance with SOZO privacy policy

1. Responding to privacy-related complaints and concerns
2. Responding to requests for access and correction
3. Responding to inquiries from the public about SOZO privacy practices

• Liaising with other organizations, the public and government, as necessary, on privacy-related issues

1. Inquiries and Complaints

1. Questions, comments or complaints about the SOZO privacy policies and procedures or about the collection, use or disclosure of personal information will be directed to the Privacy Officer.
2. The Privacy Officer will follow the procedures set out in the Grievances and Appeals policy in responding to, resolving and recording privacy-related complaints.