THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We are
required by law to maintain the privacy of your health information; to provide
you this detailed Notice of our legal duties and privacy practices relating to
your health information; and to abide by the terms of the Notice that are
currently in effect.
I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT
AND HEALTH CARE OPERATIONS
The
following lists various ways in which we may use or disclose your health
information for purposes of treatment, payment and health care operations.
For
Treatment. We will use and disclose your health
information in providing you with
services and coordinating your care and may disclose information to
other providers involved in your care. Your health information may be
used by doctors involved in your care and by nurses and health aides as well as
by physical therapists, pharmacists, suppliers of medical equipment or other
persons involved in your care. For example, we will contact your
physician to discuss your plan of care as needed.
For
Payment. We may use and disclose your health
information for billing and payment purposes. We may disclose your health
information to your representative, or to an insurance or managed care company,
Medicare, Medicaid or another third party payor. For example, we may
contact Medicare or your health plan to confirm your coverage or to request
prior approval for services that will be provided to you.
For
Health Care Operations We may disclose
your health information to another entity with which you have or had a
relationship if that entity requests your information for certain of its health
care operations or health care fraud and abuse detection or compliance
activities. For example, health information of many patients may be combined
and analyzed for purposes such as evaluating and improving quality of care and
planning for services.
II. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH
INFORMATION
The
following lists various ways in which we may use or disclose your health
information.
Individuals
Involved in Your Care or Payment for Your Care. Unless
you object, we may disclose health information about you to a family member,
close personal friend or other person you identify, including clergy, who is
involved in your care.
Emergencies. We may
use or disclose your health information as necessary in emergency treatment
situations.
As
Required By Law. We may use or disclose your health
information when required by law to do so.
Business
Associates.
We may disclose your
protected health information to a contractor or business associate who needs
the information to perform services for ThirdAge Services. Our business
associates are committed to preserving the confidentiality of this information.
Public
Health Activities. We may disclose your health information for
public health activities. These activities may include, for example, reporting
to a public health authority for preventing or controlling disease, injury or
disability; reporting abuse or neglect
or reporting births and deaths.
Reporting
Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect,
domestic or other type violence, we may use and disclose your health
information to notify a government authority, if authorized by law or if you
agree to the report.
Health
Oversight Activities. We may disclose your health
information to a health oversight agency for activities authorized by
law, such as audits, investigations, inspections and licensure actions or for
activities involving government oversight of the health care system.
To
Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or
safety or the health or safety of the public or another person, we may use or
disclose health information, limiting disclosures to someone able to help
lessen or prevent the threatened harm.
Judicial
and Administrative Proceedings. We may disclose your health information in response to a court
or administrative order. We also may disclose information in response to
a subpoena, discovery request, or other lawful process; efforts must be made to
contact you about the request or to obtain an order or agreement protecting the
information.
Law
Enforcement. We may disclose your health
information for certain law enforcement purposes, including, for example, to
comply with reporting requirements; to comply with a court order, warrant, or
similar legal process; or to answer certain requests for information concerning
crimes.
Research. We may use or disclose your health information for research
purposes if the privacy aspects of the research have been reviewed and
approved, occurs after your death, or if you authorize the use or disclosure.
Coroners,
Medical Examiners, Funeral Directors, Organ Procurement Organizations. We
may release your health information to a coroner, medical examiner, funeral
director or, if you are an organ donor, to an organization involved in the
donation of organs and tissue.
Disaster
Relief. We may disclose health information about you
to a disaster relief organization.
Military,
Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose
your health information as required by military command authorities. We
may disclose health information for national security purposes or as needed to
protect the President of the
Workers'
Compensation. We may use or disclose your health
information to comply with laws relating to workers' compensation or similar
programs.
Inmates/Law
Enforcement Custody. If you are under the custody of a law
enforcement official or a correctional institution, we may disclose your health
information to the institution or official for certain purposes including the
health and safety of you and others.
Appointment
Reminders. We may use or disclose health information to
remind you about appointments.
Treatment
Alternatives and Health-Related Benefits and Services. We
may use or disclose your health information to inform you about treatment
alternatives and health-related benefits and services that may be of interest
to you.
III.
USES AND DISCLOSURES WITH YOUR AUTHORIZATION
Except as
described in this Notice, we will use and disclose your health information only
with your written Authorization. You may revoke an Authorization in
writing at any time. If you revoke an Authorization, we will no longer use or
disclose your health information for the purposes covered by that
Authorization, except where we have already relied on the Authorization.
IV. YOUR RIGHTS REGARDING YOUR HEALTH
INFORMATION
Listed
below are your rights regarding your health information. Each of these
rights is subject to certain requirements, limitations and exceptions.
Exercise of these rights may require submitting a written request to ThirdAge
Services. At your request, ThirdAge Services will supply you with the
appropriate form to complete. You have the right to:
Request
Restrictions. You have the right to request restrictions on
our use or disclosure of your health information for treatment, payment, or
health care operations. You also have the right to request restrictions
on the health information we disclose about you to a family member, friend or
other person who is involved in your care or the payment for your care.
All requests for restrictions must be made in writing.
We are
not required to agree to your requested restriction (except that if you are
competent you may restrict disclosures to family members or friends). If
we do agree to accept your requested restriction, we will comply with your
request except as needed to provide you emergency treatment.
Access
to Personal Health Information.
You have the right to inspect
and obtain a copy of your clinical or billing records or other written
information that may be used to make decisions about your care. Your request be made in writing or verbally. In some
cases we may charge a reasonable fee for our costs in copying and mailing your
requested information.
We may
deny your request to inspect or receive copies in certain circumstances.
If you are denied access to health information, in some cases you have a right
to request review of the denial. A licensed health care professional
designated by ThirdAge Services who did not participate in the decision to deny
would perform this review.
Request
Amendment. You have the right to request amendment of
your health information maintained by ThirdAge Services for as long as the
information is kept by or for ThirdAge Services. Your request may be made
in writing or verbally, and must state the reason for the requested amendment.
We may
deny your request for amendment if the information (a) was not created by
ThirdAge Services, unless the originator of the information is no longer
available to act on your request; (b) is not part of the health information
maintained by or for ThirdAge Services; (c) is not part of the information to
which you have a right of access; or (d) is already accurate and complete, as
determine ThirdAge Services.
If we
deny your request for amendment, we will give you a written denial including
the reasons for the denial and the right to submit a written statement
disagreeing with the denial.
Request
an Accounting of Disclosures.
You have the right to request an
“accounting” of certain disclosures of your health information. This is a
listing of disclosures made by ThirdAge Services or by others on our behalf,
but does not include disclosures for treatment, payment and health care
operations, disclosure made pursuant to your Authorization, and certain other
exceptions.
To
request an accounting of disclosures, you must submit a request in writing,
stating a time period beginning after our Engagement letter with you, that is
within six years from the date of your request. The first accounting
provided within a 12-month period will be free; for further requests, we may
charge you our costs.
Request
a Paper Copy of This Notice. You have the
right to obtain a paper copy of this Notice, even if you have agreed to receive
this Notice electronically. You may request a copy of this Notice at any
time. In addition, you may obtain a copy of this Notice at our website,
www.Thirdageservices.com
Request
Confidential Communications. You have the
right to request that we communicate with you concerning your health matters in
a certain manner. We will accommodate your reasonable requests. All
requests may be made in writing or verbally.
V. FOR FURTHER INFORMATION OR TO FILE A
COMPLAINT
If you have any questions about this
Notice or would like further information concerning your privacy rights, please
contact us at our offices at
If you
believe that your privacy rights have been violated, you may file a complaint
in writing with Third Age Services or with the Office of Civil Rights in the
U.S. Department of Health and Human Services. We will not retaliate
against you if you file a complaint.
To file a complaint with Third Age
Services, contact us at our offices at
VI. CHANGES
TO THIS NOTICE
We
reserve the right to change this Notice and to make the revised or new Notice
provisions effective for all health information already received and maintained
by Third Age Services as well as for all health information we receive in the
future. We will provide a copy of the revised Notice upon request.
Summary
and Signature Page
I hereby acknowledge
that I have been provided a Privacy Notice for ThirdAge Services and understand
my rights as a client.
I understand that I
have certain rights to restrict the use and disclosure of my Protected Health
Information, to obtain a copy of the Notice of Privacy Practices.
Unless I object, my
Protected Health Information may be disclosed to assist in notifying a family
member, and/or certain other individuals responsible for my care about my
location, general condition or my death. My Protected Health Information may
also be disclosed to assist in disaster relief efforts.
I understand that
other uses of my Protected Health Information will be made only as otherwise
authorized by law or with my authorization which I may revoke except to the
extent information or actions have already been taken.
________________________________
________________
Signature
Date