4/4/03
“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.”
Laurel House Inc. is committed to protecting the privacy of your health care information, as federal and state laws allow. We know and understand how important it is to you and your family to keep your personal health information secure and private. We have been committed and will remain committed to the premise of confidentiality. This notice tells you of your rights about the privacy of your personal health information. This notice describes how Laurel House, Inc. may use and disclose Protected Health Information (PHI) to carry out treatment, payment, and health care operations and for other purposes that are permitted or required by law.
We are required by privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of Protected Health Information and to provide our consumers with notice of our legal duties and privacy practices concerning Protected Health Information. By law we are required to; maintain the privacy of your health information, give you notice of our legal duties and privacy practices and follow the terms of this notice.
This notice will remain in effect until we revise it. We reserve the right to change our privacy practices and terms of this notice and make the new notice provisions effective for all Protected Health Information that we maintain. We will make you aware of any changes by: posting the revised notice in our office, making copies of the revised notice available upon your request (either at our office, through the contact person listed in this notice, or posting the revised notice on our web site www.laurelhouseinc.org.
WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Health Information is your past, present or future physical or mental health or condition; the treatment we provide to you, or payment for your past, present, or future health care.
For Treatment: information obtained by program directors, supervisors, residential program workers (RPW), therapists, interdisciplinary team members, day program members, and healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Examples of possible uses would be: individual program plan (IPP), personal centered plans (PCP), lifetime medical, lifetime management plan (LMP), and coordinating healthcare. We may disclose protected health information about you to provide you with medical treatment or services. We may disclose this information to doctors, nurses, technicians, medical students, interns, and Provider personnel who are involved in taking care of you. Laurel House, Inc. may share your health information with people outside of the agency who may be involved in your medical care when you are absent from the agency. Examples of such persons would be family members, clergy, providers of day services, volunteers, Independent Supports Coordinators, case managers, respite care workers, transportation providers, and others we have engaged to provide services that are part of your care.
Appointment Reminders and Other Contacts: we may use your health information to contact you with reminders about your appointments, alternate treatments you may want to consider, or other services that may be of interest to you.
For Payment: We may use and disclose protected health information about you so that the treatment and services you receive from the Provider or other providers may be billed to and payment may be collected from you, the government, an insurance company or a third party. For example, we may disclose information to the county or state mental health and/or mental retardation agency in order to receive payments for your treatment. We may also tell your insurer or governmental payor about a treatment you are going to receive to obtain prior approval or to determine whether your plan or the government will cover the cost of treatment.
Health Care Operations: We may use and disclose protected health information about you for provider operations or operations of another provider or payor. These uses and disclosures are necessary to run the Provider and make sure that all of our consumers receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine protected health information about many Provider consumers to decide what additional services the Provider should offer and what services are not needed, and weather certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, direct care providers, behavioral therapists, special therapists, and other provider personnel for review and learning purposes. We may also disclose information in order to comply with our incident reporting requirements under state, local, and federal law. We may also combined the protected health information we have with protected health information from other providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study health care and health care delivery without learning who the specific clients are.
Healthcare Quality Units and Other Quality Review Organizations: we may disclose information to the Pennsylvania Department of Public Welfare, the Office of Mental Retardation, and other state and county mental health and mental retardation agencies through their appointed agents, including Health Care Quality Units and independent monitoring groups, in order to comply with Federal, state, and local laws and regulations.
Treatment Alternatives: We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-related Benefits and Services: We may use and disclose protected health information to tell you about health-related benefits or services that may be of interest to you.
Fundraising Activities: We may use contact information, such as your name, address and phone number, and the dates you received treatment or services from the provider to contact you and your family members in an effort to raise money for the provider. We may disclose this contact information to a foundation related to the provider so that the foundation may contact you and your family members in raising money for the provider. If you do not want the Provider or the foundation to contact you or your family members for fundraising efforts, you must notify the Privacy Officer in writing.
Provider Directory: We may include certain limited information about you in the Provider Directory while you are a consumer of the Provider. This information may include your name; location at Provider, your general condition, and your religious affiliation, this information may be given to a member of the clergy, such as a priest or Rabbi, even if they do not ask for you by name. This is so your family, friends, and clergy can visit you at the Provider and generally know how you are doing.
Individuals Involved in Your Care or Payment for your Care: We may disclose protected health information about you to your family members, your personal friends or any other person identified by you, but we will only disclose information that we feel is relevant to that person’s involvement in your care or the payment for your care. If you are feeling well enough to make decisions about your care, we will follow your directions as to who is sufficiently involved in your care to receive information. If you are not present or cannot make these decisions, we will make a decision based on weather we believe it is in your best interest for a family member or friend to receive private health information and how much information they should receive. Obviously, we are inclined to provide greater information to close family members than to friends.
We may also disclose information to disaster relief agencies or to family, friends, or others in an effort to locate or identify family members or personal representatives.
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 progress of all consumers who received one therapy 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 consumers’ 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 clients with specific medical needs, so long as the protected health information they review does not leave the Provider. In certain situations, we are required to ask your specific permission, such as when 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 Provider.
As Required by Law: We will disclose protected health information about you when required to do so by federal, state, or local law. For instance, the Provider is obligated to report to public health officials the occurrence of certain communicable diseases, or acts of violence. Additionally, the Provider is required to report certain incidents to the Pennsylvania Department of Public Welfare.
To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat.
Day Providers: We may use and disclose information about you if necessary to facilitate your application for admission to, or use of, day programs such as supported employment and sheltered employment.
Residential Facilities: We may use and disclose information about you if necessary to facilitate your application for admission into, or use of residential facilities.
In -Home Services: We may use and disclose information about you if necessary to facilitate your application for, or use of, in-home services.
Family Living Arrangements: We may use and disclose information about you if necessary to facilitate your application for admission into, or use of, family living arrangements.
Supports Coordinators: We may use and disclose information about for as necessary for supports coordinators and case managers to complete their duties for you.
Transfers: We may use and disclose information about you to another provider to which you are being transferred or which is considering you a transfer.
Employers: We may use and disclose information about you to an employer or prospective employer in connection with your application for, or continuation of, employment.
Organ and Tissue Donations: If you are an organ or tissue donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release protected health information about you as required by military command authorities.
We may also release protected health information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation: We may release protected health information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness. Under the privacy regulations, worker’s compensation claims are exempted for coverage, and thus we may release protected health information about you to your employer for worker’s compensation services.
Public Health Risks: We may disclose protected health information about you for public health activities. These activities generally include the following:
v To prevent or control disease, injury or disability;
v To report births or deaths;
v To report child abuse or neglect;
v To report reactions to medications or problems with products;
v To notify people of recalls of products they may be using;
v To notify a person who may have been exposed to a disease or maybe at risk for contracting or spreading a disease or condition;
v To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities: We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. The federal government has determined that it must have access to this information to adequately monitor beneficiary eligibility for government programs (for example, Medicare or Medicaid), compliance with program standards, and/ or civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if appropriate efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release protected health information if asked to do so by a law enforcement official:
v In response to a court order, subpoena, warrant, summons or similar process;
v To identify or locate a suspect, fugitive, material witness, or missing person;
v About the victim of a crime if, under certain limited circumstances, we are unable to obtain the persons agreement;
v About a death we believe may be the result of criminal conduct;
v About criminal conduct at the Provider; and
v 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.
Coroners, medical examiners, and funeral directors: We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected health information about clients of the provider to funeral directors as necessary to allow them to carry out their duties.
National Security and Intelligence Activity: We may release protected health information about you to authorized federal officials for intelligence, counter intelligence, and other national securities authorized by law.
Protected services for the President and Others: We may disclose protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are and inmate of a correctional institution or under the custody of law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary
(1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
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 Privacy Officer.
If you request a copy of the information, we customarily 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 protected health information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the Provider 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 Append and Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to append or amend the information. You have the right to request an amendment for as long as the information is kept for the Provider. If we do not agree to amend your information, you may add a supplemental statement to your records indicating why you believe the information should changed. We will append or otherwise link your statement to your records.
To request an amendment, your request must be made in writing and submitted to the Privacy Officer. 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:
v Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
v Is not part of the protected health information kept by or for the Provider;
v Is not part of the information which you would be permitted to inspect and copy; or
v Is accurate and complete.
Right to accounting of disclosures: You have the right to request an “accounting of disclosures.” This is a list of several types of 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 Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include disclosures before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
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 could ask that we not use or disclose information about a surgery you had.
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 Privacy Officer. 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 a paper copy of this notice. You may ask us to give you a copy of this notice at anytime. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, www.laurelhouseinc.org
To obtain a paper copy of this notice, please write or call Robert V. Nicol, Privacy Officer, 197 West Main Street, Uniontown, PA 15401 (724) 437-1129
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 at our site. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to the Provider for treatment or health care services as a client, we would offer you a copy of the current notice of effect.
If you believe your privacy rights have been violated, you may file a complaint with the Provider or with the Secretary of the Department of Health and Human Services. To file a complaint with the Provider, contact Robert V. Nicol, Privacy Officer, 197 West Main Street, Uniontown, PA 15401 (724) 437-1129. All complaints must be in writing.
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.
I acknowledge that I have received a copy of Laurel House, Incorporated Notice of Privacy Practices with the effective date of April 14, 2003.
_______________________________________ __________
Printed Name of Consumer or Consumer Representative Date
_______________________________________
Signature
_______________________________________
Relationship to Consumer
Please return this form to Robert V. Nicol, Privacy Officer, at:
Laurel House, Inc.
197 West Main Street
Uniontown, PA 15401