THIS
NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Each
time you visit a provider, a record of your visit is made. Typically, this
record contains your diagnoses, treatment, and a plan for future care or
treatment. This information, often referred to as your record, serves as a:
· basis for planning and
providing your care and treatment
· means of communication among
the many health professionals who contribute to your care
· legal document describing
the care you received
· means by which you or a
third-party payer can verify that services billed were actually provided
· a tool in educating heath
professionals
· a source of data for medical
research
· a source of information for
public health officials who oversee the delivery of health care in the United
States
· a tool with which we can
assess and continually work to improve the care we render and the outcomes we
achieve
Understanding what is in
your record and how your health information is used helps you to: ensure its
accuracy, better understand who, what, when, where, and why others may access
your health information, and make more informed decisions when authorizing
disclosure to others.
Our
Responsibilities
Our
facility/agency is required to:
· maintain the privacy of your
health information
· provide you with a Notice as
to our legal duties and privacy practices with respect to information we
collect and maintain about you
· abide by the terms of this
Notice
· notify you if we are unable
to agree to a requested restriction
· accommodate reasonable
requests you may have to communicate health information by alternative means or
at alternative locations.
We reserve the right to
change our practices and to make the new provisions effective for all protected
health information we maintain. Should our information practices change, we
will mail you a revised notice.
We will not use or disclose your
health information without your authorization, except as described in this
notice.
Except as
prohibited by federal and state regulations (Drug & Alcohol-42 CFR Part 2
or Mental Health/Mental Retardation-MH/MR Act of 1966) we will adhere to the
following stipulations:
.
(1)
Treatment. We will use your health information for
treatment without your consent. For example, information obtained by a
psychologist, therapist, or other member of your healthcare team will be
recorded in your record and used to determine the course of treatment that
should work best for you. Your health care professional/casemanager/clinical
director/etc. will document in your record his or her expectations of the
members of your healthcare team.
Members of your healthcare team will then record the actions they took
and their observations. In that way, the health care
professional/casemanager/clinical director/etc. will know how you are
responding to treatment. We will also provide your health care
professional/casemanager/clinical director/etc. or a subsequent healthcare
provider with copies of various reports that should assist him or her in treating
you once you are discharged from our facility/agency.
(2)
Payment. We will use your health information for
payment without your consent from the third party payer you designate,
including Medicare and Medicaid. A bill may be sent to you or any private or public
source of health coverage you have identified. The information on or
accompanying the bill will be limited to that information necessary to
establish the claims for which reimbursement is sought. For example, the bill may include
information that identifies you such as diagnosis, procedures, and supplies
used, dates, types and costs of therapies and services, and a general
description of the general purpose of each treatment session or service.
(3)
Health
care operations. We will use your health information for regular health
operations without your consent. For example, members of the staff, the risk or
quality assurance manager may use information in your health record to assess
the care and outcomes in your case and others like it. This information will
then be used in an effort to continually improve the quality and effectiveness
of the health care and service we provide.
(4)
Notification. Using our professional judgment, we may use
or disclose information to notify or assist in notifying a family member,
personal representative, or another person responsible for your care, of your
location, and general condition.
(5)
Communication
with family. With your written
permission, we may disclose to a family member, other relative, close personal friend
or any other person you identify, health information relevant to that person's
involvement in your care or payment related to your care
(6)
Research.
We may disclose information to researchers when an institutional review board
that has reviewed the research proposal and established protocols to ensure the
privacy of your health information has approved their research.
(7)
The
TCDHS Administrator. Without your consent we are permitted to share certain
portions of your Protected Health Information with the TCDHS Administrator who
is responsible for overseeing this facility and must receive information
regarding the operation of this facility as required in certain circumstances
as permitted by law
(8)
Commitment
Proceedings. During the course of an
involuntary commitment proceeding, the court may direct that it or a mental
health review officer, as allowed under the Mental Health Procedures Act to
have access to your PHI for purposes of conducting the hearing without your
consent. Also, information will be disclosed
to attorneys assigned to represent you if you are the subject of an involuntary
commitment proceeding without your consent.
(9)
Food
and Drug Administration (FDA). We may disclose to the FDA health information
relative to adverse events with respect to food, supplements, product and
product defects, or post marketing surveillance information to enable product
recalls, repairs, or replacement.
(10)Public health. As required
by law, we may disclose your health information without your consent to public
health or legal authorities charged with preventing or controlling disease,
injury, or disability.
(11)Correctional institution.
Should you be an inmate of a correctional institution, we may disclose to the
health care professionals at the institution, without your consent, health
information necessary for your health treatment.
(12)Business Associates. There
are some services provided for our organization through contracts with business
associates. When these services are contracted, we may disclose your health information
to our business associate so they can perform the job we’ve asked them to do.
However, we require the business associate to appropriately safeguard your
information.
(13)Coroners, Medical Examiners,
and Funeral Directors. We may disclose health information to funeral directors
to carry out their duties, as required by law.
(14)Law Enforcement. We may
disclose health information for law enforcement purposes.
· In response to a court
order, subpoena, warrant, summons or similar process;
· To identify or located a
suspect, fugitive, material witness, or missing person;
· About the victim of a crime
if, under certain limited circumstances, we are unable to obtain the person's
agreement;
· About a death we believe may
be the result of criminal conduct;
· About criminal conduct at
the agency; and
· In emergency circumstances
to report a crime; the location of the crime or victims; or the identity,
description or location of the person who committed the crime.
(15)Military and Veterans. If you
are a member of the armed forces, we may release medical information about you
as required by military command authorities. We may also release medical
information about foreign military personnel to the appropriate foreign
military authority.
Although your health record
is the physical property of the provider, the information in your health record
belongs to you. You have the following rights:
· You may request that we not
use or disclose your health information for a particular reason related to
treatment, payment, or general health care operations, and/or to a personal
representative or guardian. We ask that such requests be made in writing on a
form provided by TCDHS and submitted to the Privacy Officer, Tioga County Department
of Human Services, P.O. Box 766, Wellsboro, PA 16901. Although we will
consider your request, please be aware that we are under no obligation to
accept it or to abide by it.
· If you are dissatisfied with
the manner in which or the location where you are receiving communications from
us that are related to your health information, you may request that we provide
you with such information by alternative means or at alternative locations.
Such a request must be made in writing on a form provided by TCDHS, and
submitted to the Privacy Officer, Tioga County Department of Human Services,
P.O. Box 766, Wellsboro, PA 16901. We will attempt to accommodate all
reasonable requests.
· You may request to inspect
and/or obtain copies of health information about you, which will be provided to
you in the time frames established by law. If you request copies we will charge
you a reasonable fee.
· If you believe that any
health information in your record is incorrect or if you believe that important
information is missing, you may request that we correct the existing
information or add the missing information. Such requests must be made in
writing, and must provide a reason to support the amendment. We ask that you
use the form provided by our facility to make such requests. For a request
form, please contact your casemanager/therapist/ program worker or the Privacy
Officer at Tioga County Department of Human Services, P.O. Box 766,
Wellsboro, PA 16901.
· You may request that we
provide you with a written accounting of all disclosures made by us during the
time period for which you request (not to exceed 6 years). We ask that such
requests be made in writing on a form provided by TCDHS, and submitted to the Privacy
Officer, Tioga County Department of Human Services, P.O. Box 766, Wellsboro, PA
16901. Please note that an accounting will not apply to any of the
following types of disclosures: disclosures made for reasons of treatment,
payment or health care operations; disclosures made to you or your legal
representative, or any other individual involved with your care; disclosures to
correctional institutions or law enforcement officials; and disclosures for
which a valid authorization is on file. You will not be charged for your first
accounting request in any 12-month period. However, for any requests that you
make thereafter, you will be charged a reasonable, cost-based fee.
· You have the right to obtain
a paper copy of our Notice of Privacy Practices upon request.
· You may revoke an
authorization to use or disclose health information, except to the extent that
action has already been taken. Such a request must be made in writing.
If you have questions and would
like additional information, you may contact our Privacy Officer at the Tioga
County Department of Human Services, P.O. Box 766, Wellsboro, PA 16901
If
you believe that your privacy rights have been violated, you may file a
complaint with us. These complaints must be filed in writing on a form provided
by our facility. The complaint form may be obtained from your
casemanager/therapist/program worker or the Privacy Officer at the above
address and when completed should be returned to your casemanager/therapist/program
worker or the Privacy Officer. You may also file a complaint with the secretary
of the federal Department of Health and Human Services, 200 Independence Ave.,
S.W., Washington, D.C. 20201. There will be no retaliation for filing a complaint.
TIOGA COUNTY
DEPARTMENT OF HUMAN SERVICES
(TCDHS)
I, ________________________________________, have received and reviewed a copy
(Consumer or Authorized
Representative)
the TCDHS Notice of Privacy Practices. I acknowledge that I have read and understand
the Notice and my rights as outlined therein. Questions that I have had regarding the
Notice have been answered by TCDHS staff.
__________________________________________
(Signature
of Consumer or Authorized Representative) (Date)