This notice describes how protected health information
about you may be used and disclosed and how you can gain access to this information.
Please review it carefully.
If you have any questions about this Notice, please contact: The Region IV Area Agency on Aging (R4AAA), Privacy Officer at (269) 983-0177 or 1-800-442-2803
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
We
are required to abide by the terms of this Notice of Privacy Practices. We will provide you with any revised Notice
of Privacy Practices if you call our office and request that a revised copy be
sent to you in the mail or if you ask for a copy at your next reassessment.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
I. Uses and Disclosures of Protected Health Information Based upon Your Written Consent
You will be asked by your care manager to sign a
consent form. Once you have consented to
the use and disclosure of your protected health information for treatment,
payment and health care operations by signing the consent form, your care
manager will use or disclose your protected health information as described in
this Section (I.). Your protected health
information may also be used and disclosed to pay your health care bills and to
submit claims to Medicaid, Medicare or third party insurers for
reimbursement. Following are example of
the types of uses and disclosures of your protected health information that R4AAA
is permitted to make once you have signed our consent form. These examples are meant to describe the
types of uses and disclosures that may be made once consent is provided, but
may not necessarily be disclosed for you:
TREATMENT
We will use and disclose your protected health
information to provide, coordinate or manage your health care and any related
services. This includes the coordination
or management of your treatment plan with our network of service
providers. For example, we would
disclose your protected health information with a home health agency that will
provide personal care to you. A listing
of your providers (a care plan report) will be discussed with you at each reassessment,
and you may request a copy of the care plan report at the reassessment. In addition, we may disclose your protected
health information from time-to-time with your physician or other specialist
who becomes involved in your care by providing assistance with your health care
diagnosis or treatment plan.
PAYMENT
Your protected health information will be used, as
needed, to obtain payment for your health care services. This may include certain activities that
Medicaid, Medicare or another health insurance plan may undertake before it
approves or pays for your health care services such as making a determination
of your eligibility or reviewing services provided to you as appropriate and
necessary, and undertaking utilization review activities.
HEALTHCARE OPERATIONS
We may use or disclose, as needed, your protected
health information in order to support business activities including, but not
limited to, quality assurance reviews, care manager trainings, peer reviews,
Medicaid or Medicare or other health insurance plan audit reviews, and
independent financial audits.
For example, we may disclose your protected health
information with third party “business associates” that perform various
activities like billing or claim submission services for R4AAA. Whenever an arrangement between our office
and a business associate involves the use or disclosure of your protected
health information, we will have a written contract with the business associate
that will protect the privacy of your protected health information.
We may disclose your protected health information,
as necessary, to contact you monthly to check on your health status, to arrange
for your next home visit by your care manager or to remind you of your next
appointment for a home visit. We may
also call you by name in our waiting room if you visit R4AAA to see your care
manager.
We may also send you information about services we
feel may be beneficial to you, notify you about our fundraising efforts or send
you our newsletters. You may contact our
Privacy Contact Person to request that these materials not be sent to you.
We may use or disclose your protected health
information that directly relates to the provision of your health care in your
home to an individual or agency from our pool of service providers. Only the
protected health information that is relevant for the provider to deliver
comprehensive health care service(s) will be disclosed.
INDIVIDUALS
INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE.
We may release protected health information about
you to a friend or family member who is involved in your medical care. We may also give information to someone who
helps pay for your care. We may also
tell your family or friends your conditions and that you are involved with our
program. In addition we may disclose
protected health information about you to an entity assisting in a disaster
relief effort so that your family can
be notified about your condition, status, and location.
RESEARCH
Under certain circumstances, we may use and disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all participants who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of protected health information, trying to balance the research needs with participants’ need for privacy of their protected health information. Before we use or disclose protected health information for research, the project will have been approved through this research approval process, but we may, however, disclose protected health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the protected health information they review does not leave the agency. We will almost always ask for your specific permission or authorization if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the agency.
II. Uses and Disclosures of Protected Health Information Based upon your Written Authorization
Other uses and disclosures of your protected health
information will be made only with your written authorization, unless otherwise
permitted or required by law. You may
revoke any written authorization at any time in writing, except to the extent
that your care manager has taken an action already in progress in reliance on
the use or disclosure indicated in the previously signed authorization.
III. Other Permitted and Required Uses and Disclosures that May Be Made with Your Consent, Authorization or Opportunity to Object
You have the opportunity to agree or object to the
use or disclosure of all or part of your protected health information. If you are not present or able to agree or
object to the use or disclosure of the protected health information, then your
care manager may, using professional judgment, determine whether the disclosure
is in your best interest. In this case,
only the protected health information that is relevant to your health care will
be disclosed.
YOUR RIGHTS REGARDING
PROTECTED HEALTH INFORMATION ABOUT YOU
I. You have the following rights regarding
protected health information we maintain about you:
RIGHT TO INSPECT AND COPY
You have the right to inspect and copy protected
health information that may be used to make decisions about your care. Usually,
this includes medical and billing records, but does not include psychotherapy
notes. To inspect and copy protected health information that may be used
to make decisions about you, you must submit your request in writing to the
agency.
If you request a copy of the information, we may charge a fee for the
costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy
in certain very limited circumstances. If you are denied access to medical
information, you may request that the denial be reviewed. Another supervisor or
director chosen by the agency will review your request and the denial. The
person conducting the review will not be the person who denied your request. We
will comply with the outcome of the review.
RIGHT
TO AMEND
If you feel that protected 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 for as long as the information is kept by or for the agency. To request an amendment, your request
must be made in writing and submitted to the agency. In addition, you must provide a
reason that supports your request. We
may deny your request for an amendment if it is not in writing or does not
include a reason to support the request. In addition, we may deny your request
if you ask us to amend information that was not created by us, unless the
person or entity that created the information is no longer available to make
the amendment or that is not part of the protected health information kept by
or for the agency, or is not part of the information which you would be
permitted to inspect and copy, or that is accurate and complete.
RIGHT
TO AN ACCOUNTING OF DISCLOSURES
You have the right to request an "accounting of
disclosures." This is a list of the disclosures we made of protected
health information about you. To request this list or accounting of
disclosures, you must submit your request in writing to the agency. Your request
must state a time period which may not be longer than six years and may not
include dates before
RIGHT
TO REQUEST RESTRICTIONS
You have the right to request a restriction or
limitation on the protected 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 protected health
information we disclose about you to
someone who is involved in your care or the payment for your care, like a
family member or friend. For example, you may not want your spouse to know
anything about your services unless it’s an emergency. 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. To request
restrictions, you must make your request in writing to the agency. In your
request, you must tell us (1) what information you want to limit; (2) whether
you want to limit our use, disclosure or both; and (3) to whom you want the limits
to apply, for example, disclosures to your spouse.
RIGHT
TO REQUEST 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 must make your request in writing to the agency. 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 A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You
may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you
are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, call
the agency at (269) 983-0177 or 1-800-442-2803.
RIGHT TO FILE A COMPLAINT
You have the right to file a formal complaint if you
believe your privacy rights have been violated, You may file a complaint with
this agency or with the secretary of the department of health and human
services. To file a complaint with this
agency, please contact the Privacy Officer, at (269) 983-0177 or 1-800-442-2803. All complaints must be submitted in
writing.
You will not be penalized for filing a complaint.
We reserve the right to
change this notice. We reserve the right to make the revised or changed notice
effective for protected health information
we already have about you as well as any information we receive in the
future. We will post a copy of the current notice in our office and on our
website. The notice will contain the effective date on the bottom right corner
of the actual notice, and on the main page on the website.