Privacy Notice
Patient Acknowledgement
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
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.
This Notice is effective beginning April 14, 2003.
All About You Home Care Services is required by law to maintain the privacy of protected health information and to provide you with notice of its legal duties and privacy practices with respect to such information. All About You Home Care Services will abide by the terms of the notice currentlyin effect; however, All About You Home Care Services reserves the right to change the terms of this notice as well as make the new provisions effective for all protected health information maintained. If there is a change, All About You Home Care Services will inform you of this change at your next scheduled appointment or upon your request. In addition,a copy of the effective notice will be posted at all times in the office with a date notifying you of the most recent update.
As a patient of All About You Home Care Services, information about you must be used and disclosed to other parties for purposes of treatment, payment, and health care operations. These uses and disclosures do not require your consent and include, but are not limited to release of information contained infinancial records, medical records, laboratory test results, medical history, treatment progress or any other related information to:
1 Your insurance company,self funded or third-party healthplan,Medicare,Medicaid,or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;
2 Any person or entity affiliated with or representing for purposes of administration, billing, and quality and risk management;
3 Any hospital, nursing home, or other healthcare facility to which you may be admitted;
4 Any assisted living or personal care facility of which you are a resident;
5 Any physician providing you care;
6 Any business associate of All About You Home Care Services that agrees to abide by the privacy requirements regarding your protected health information; and
7 Licensing and accrediting bodies, including the information contained in the Oasis Data Set to the State agency acting as representative of the Medicare/Medicaid program.
In addition,All About You Home Care Services may contact you:
1 To provide appointment reminders or information about other health activities we provide;and
2 To raise funds for All About You Home Care Services.
All About You Home Care Services is also permitted to use or disclose information about you without consent or authorization in the following circumstances;
1. Where the use or disclosure is required by another law, but only to the extent that it is required and complies with such other law;
2. For certain public health activities;
3. Where AllAboutYouHomeCareServices reasonably believes you are a victim of abuse, neglect, or domestic violence, but only to a government authority authorized to receive abuse, neglect or domestic violence complaints.
4. Health care oversight activities;
5. Certain judicial and administrative proceedings;
6. Certain law enforcement purposes;
7. To coroners, medical examiners and funeral directors, in certain circumstances;
8. For cadaveric organ, eye or tissue donation purposes;
9. For certain research purposes;
10. To avert a serious threat to health and safety;
11. For specialized government functions, including military and veterans’activities,national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations;and
12. For workers’ compensation purposes.
All About You Home Care Services is permitted to use ordisclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit orrestrict the disclosure in the following circumstances:
1. For use in a directory of individuals served by All About You Home Care Services (such information is limited to the individual’s name, location within the facility, condition in general terms, and religious affiliation);
1 To a family member, other close relative, close personal friend, or other identified person, the information relevant to such person’s involvement in your care or payment for care.
2 To a public or private entity authorized by law or charter to assist in disaster relief efforts, but only for the purpose of coordinating with such entities.
Other uses and disclosures not specifically addressed earlier in this notice will be made only with your written authorization. In addition, Connecticut law requires an authorization to disclose highly sensitive information, including communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records, and genetic testing information.
Examples of when authorization is required forAllAboutYou Home Care Services to use or disclose your protectedhealth information include:
1 Psychotherapy notes (not withstanding the provisions that allow the use and disclosure of protected health information without consentand authorization for treatment, payment and healthcare operations, the law specifically requires an authorization to use or disclose psychotherapy notes);
2 Marketing, except if the communication is in the form of a face-to-face communication made by All About You Home Care Services to you or a promotional gift of nominal value provided by All About You Home Care Services;
These authorizations may be revoked, in writing, at any time, except in limited situations.
YOUR RIGHTS
The Health Insurance Portability Accountability Act gives you certain rights with regard to your protected health information.Any of these rights may be exercised by contacting All About You! Homecare Services and in some situations, may require you to fill out a written request.You have the right, subject to certain conditions, to:
1 Request restrictions on the use and disclosure of information about you for treatment, payment and healthcare operations, and to friends and family involved in the individual’s care. However, the All About You Home Care Services is not required to agree to the requested restriction;
2 Receive confidential communication of protected health information;
3 Inspect and copy protected health information;
4 Amend protected health information;
5 Receive an accounting of disclosures of protected health information;and
6 Obtain a papercopy of this notice, even if you agreed to receive this notice electronically.
In addition, Connecticut state law may provide you with greater protection than the Health Insurance Portability Accountability Act. In situations where this is the case, All About You! Homecare Services will be in compliance with the applicable Connecticut law.
COMPLAINTS
If you believe that your privacy rights have been violated, you may complain to both All AboutYou! Homecare Services and the Office of theSecretary at the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. Complaints may be made to the Privacy Official at All About You Home Care Services at (203) 720-9383. We recommend that complaints be given to the Privacy Official in writing, stating the specific incident(s) in terms of subject,date, and other relevant matters. Complaints to the Office of the Secretary may be made in writing to the following address:The U.S. Department of Health and Human Services, Office of the Secretary, 200 Independence Avenue, S.W., Washington, D.C. 20201. Complaints may also be made by phone to: (202) 619-0257 or Toll Free: 1-877-696-6775.
I have read or have had explained this Notice to me. I understand this notice and have had the opportunity to ask questions regarding any matters of concern.
Patient Signature / Date
