HIPAA Notification of Privacy Practices
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.
USE AND DISCLOSURE OF HEALTH INFORMATION
The Agency may use your health information, information that constitutes protected health
information as defined in the Privacy Rule of the Administrative Simplification provisions of
the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you
treatment, obtaining payment for your care and conducting health care operations. The Agency has
established policies to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH
INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment. The Agency may use your health information to coordinate care within the
Agency and with others involved in your care, such as your attending physician and other health care
professionals who have agreed to assist the Agency in coordinating care. For example,
physicians involved in your care will need information about your symptoms in order to prescribe appropriate
medications. The Agency also may disclose your health care information to individuals outside
of the Agency involved in your care including family members, pharmacists, suppliers of medical
equipment or other health care professionals.
To Obtain Payment. The Agency may include your health information in invoices to collect payment from
third parties for the care you receive from the Agency. For example, the Agency may be required
by your health insurer to provide information regarding your health care status so that the
insurer will reimburse you or the Agency. The Agency also may need to obtain prior approval from
your insurer and may need to explain to the insurer your need for home care and the services that will be provided to you.
To Conduct Health Care Operations. The Agency may use and disclose health information for its own operations
in order to facilitate the function of the Agency and as necessary to provide quality care
to all of the Agency's patients. Health care operations include such activities as:
• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management, and care coordination.
• Contacting health care providers and patients with information about treatment alternatives
and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Training on non-health care professionals.
• Accreditation, certification, licensing or credentialing activities.
• Review and auditing, including compliance reviews, medical review, legal services, and compliance
• Business planning and development including cost management and planning related analyses
and formulary development.
• Business management and general administrative activities of the Agency.
• Fundraising for the benefit of the Agency.
For example,e the Agency may use your health information to evaluate its staff performance, combi
e your _health information with other Agency patients in evaluating how to more effectively serve
all Agency patients,_disclose_ your health information to Agency staff and contracted personnel
for training purposes, use your health information.
'.o contact you as a reminder regarding a visit to you, or contact you as part of general
fundraising and community information mailings (unless you tell us you do not want to be
For Fundraising Activities. The Agency may use information about you including your name,
address, phone number and the dates you received care in order to contact you to raise money for the
Agency. The Agency may also release this information to a related Agency foundation. If
you do: not want the Agency to contact you, notify
Privacy Officer and indicate that you do not wish to be contacted.
For Appointment Reminders. The Agency may use and disclose your health information to contact you as
a reminder that you have an appointment for a home visit.
For Treatment Alternatives. The Agency may use and disclose your health information to tell you
about or recommend possible treatment options or alternatives that may be of interest to you.
THE FOLLOWING IS A SUMMARY OF THE CIRCU MSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH
INFORMATION MAY ALSO BE USED AND DISCLOSED (check your State laws to ensure consistency with State law requirements).
When Legally Required. The Agency will disclose your health information when it is required to do
so by any Federal, State or local law.
When There Are Risks to Public Health. The Agency may disclose your health information for public
activities and purposes in order to:
• Prevent or control disease, injury or disability, report disease, injury, vital events such
as birth or death and the conduct of public health surveillance, investigations and interventions.
• Report adverse events, product defects, to track products or enable product recalls, repairs
and replacements and to conduct post-marketing surveillance and compliance with requirements of
the Food and Drug Administration.
• Notify a person who has been exposed to a communicable disease or who may be at risk of
contracting or spreading a disease.
• Notify and employer about an individual who is a member of the workforce as legally
To Report Abuse, Neglect Or Domestic Violence. The Agency is allowed to notify government
authorities if the Agency believes a patient is the victim of abuse, neglect or domestic
violence. The Agency will make this disclosure only when specifically required or authorized by
law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities. The Agency may disclose your hea th information to a
health oversight agency for activities including audits, civil administrative or criminal
investigations, inspections, licensure or disciplinary action. The Agency, however, may not
disclose your health information if you are the subject of an investigation is not directly
related to your receipt of health care or public benefits.
In Connection With Judicial and Administrative Proceedings. The Agency may disclose your health
information in the course of any judicial or administrative proceeding in response to an order of
a court or administrative tribunal as expressly authorized by such order or in response to a
subpoena, discovery request or other lawful process, but only when the Agency makes reasonable
efforts to either notify you about the request or to obtain an order protecting your health
For Law Enforcement Purposes. As permitted or required by State law, the Agency may disclose your
health information to a law enforcement official for certain law enforcement purposes as follows:
• As required by law for reporting of certain types of wounds or other physical injuries pursuant to
the court order, warrant, subpoena or summons or similar process.
• For the purpose of identifying or locating a suspect, fugitive, material witness or missing
• Under certain limited circumstances, when you are the victim of a crime.
• To a law_ enforcement official if the Agency has a suspicion that your death was the result
conduct including criminal conduct at the Agency.
• In an emergency in order to report a crime.
To Coroners and Medical Examiners. The Agency may disclose your health information to coroners
and medical examiners for purposes of determining your cause of death or for other duties, as
authorized by law.
To f uneral Directors. The Agency may disclose your health information to funeral directors
consistent with applicable la:" and if necessary, to carry out their duties with respect to your
funeral arrangements. If necessary to carry out the1r duties, the Agency may disclose your health
information prior to and in reasonable anticipation of your death.
For Organ, Eye or Tissue Donation. The Agency may use or disclose your health information to
pro urement organizations or other entities engaged in the procurement, banking or
transplantation of organs, eyes or tissue fur the purpose of facilitat ng the donation and
For Research Purposes. The Agency may, under very select circumstances, use your health information
for research. Before the Agency discloses any of your health information for such research
purposes, the project will be subject to an extensive approval process. (If the Agency intends to
routinely conduct research it.is important to carefully review the authorization requirements for
research exceptions and revise the Notice provisions as needed.)
believes that such disclosure is necessary to prevent or lessen a serious and imminent faith,
law and ethical standards of conduct, disclose your health information if the Agency, in good
The Agency may, consistent with applicable In the Event of a Serious Threat to Health or Safety.threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize the
Agency to use or disclose your health information to facilitate specified government functions
relating to military _and_ eterans, national security and intelligence activities, protective
services for the President and others, medical smtabilrty determinations and inmates and law
For Worker's Compensation. The Agency may release your health information for worker's
compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, the Agency will not disclose your health information other than with
your . written authorization. If you or your representative authorizes the Agency to use or
disclose your health mformation, you may revoke that authorization in writing al any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health. information that the Agency maintains:
• Right to request restrictions. You may request restrictions on certain uses and disclosures
? your health information. You have the right to request a limit on the Agency's
disclosure of your healt mformat on to someone who is involved in your care or the payment of your
care. However, the Agency rs not re uired to agree to your request. If you wish to make a
request for restrictions, please contact the Privacy Officer.
• Right to receive confidential communications. You have the right to request that the
Agency communicate with you in a certain way. For example, you may ask that the Agency only
co?duct communications pertaining to your health information with you privately with no other
family members present. If you wish to receive confidential communications, please contact Privacy
Officer. The Agency will not request that you provide any reasons for your request and will attempt
to honor your reasonable requests for confidential communications.
• Right to inspect and copy your health information. You have the right to inspect and
copy your health information, including billing records. A requesl to inspect and copy records containing
your health information may be made to the Privacy Officer. If you request a copy of your health information,
the Agency may charge a reasonable fee for copying and assembling costs associated with your
• Right to amend health care information. You or your representatives have the right to request that
the Agency amend your records if you believe that your health information is incorrect or incomplete
. That request may be made as long as the information is maintained by the Agency. A
request for an amendment of '. cords must be made in writing to Privacy Officer. The Agency may deny
the request if it is not in writing or does not include a reason for the amendment. The request
also may be denied if your health information records were not created by the Agency,
• if the records you are requesting are not part of the Agency's records, if the health
information you wish to amend is not part of the health information you or your representative are permitted to inspect
and copy, or if, in the opinion of the Agency, the records containing your health information
are accurate and complete.
• Right to an accounting. You or your representative have the right to request an accounting of
of your health information made by the Agency for certain reasons, including reasons related to
public purposes authorized by law and certain research. The request for an accounting must be made
in writing to Privacy Officer. The request should specify the time period for the accounting
starting on or after April 14, 2003. Accounting requests may not be made for periods of time in
excess of six (6) years. The Agency would provide the first accounting you request during any
12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based
• Right to a paper copy of this notice. You or your representatives have a right to a separate
paper copy of
this Notice at any time even if you or your representative have received this Notice previously.
To obtain a separate paper copy, please contact the Privacy Officer.
DUTIES OF THE AGENCY
The Agency is required by law to maintain the privacy of your health information and to
provide to you and your representative this Notice of its duties and privacy practices. The Agency is
required to abide by the terms of this Notice of its duties and privacy practices. The Agency is
required to abide by the terms of this Notice as may be amended from time to time. The Agency reserves
the right to change the terms of its Notice and to make the new Notice provisions effective
for all health information that it maintains. If the Agency changes its Notice, the
Agency will provide a copy of the revised Notice to you or your appointed representative. You or
your personal representative have the right to express complaints to the Agency and to the
Secretary of DADS if you or your . representative believe that your privacy rights have been violated
. Any complaints to the Agency sho ld be madem writing to Privacy Officer. The Agency
·encourages you to express any concerns you may have regardmg the pnvacy of your information. You
will not be retaliated against in any way for filing a complaint.
The Agency has designated the Privacy Officer as its contact person for all issues regarding patient yourrights under the Federal privacy standards. You may contact this person at email@example.com
This Notice is effective April 14, 2003. HCL HIPAA NotifofPrivac042005