NOTICE TO PARTICIPANTS OF PRIVACY PRACTICES
EASTER SEALS-GOODWILL NORTHERN ROCKY MOUNTAIN INC.
CONTACT: Privacy Officer John Martin firstname.lastname@example.org or (208) 378-9924
Effective Date: 4/14/2003 Revised: 9/5/2013
In the course of providing services to you, Easter Seals-Goodwill may create or receive medical information about you. This notice describes how your medical information may be used and disclosed and how you can access to this information. Please review it carefully.
I. Uses and Disclosures of Medical Information Without Authorization.
We may use or disclose protected health information for the following purposes without your authorization. These examples are not meant to be exhaustive.
Treatment. We may use or disclose protected health information to provide medical services to you. For example, our staff may use information in your medical records to understand or treat a medical condition. Also, we may disclose your information to health care providers so that they may help treat you.
Payment. We may use or disclose protected health information to obtain payment for services provided to you. For example, we may disclose information from your medical records to your health insurance company or a payor to obtain pre-authorization for treatment or submit a claim for payment.
Health Care Operations. We may use or disclose protected health information for certain health care operations that are necessary to manage our company and ensure you receive quality care. For example, we may use information from your medical records to review the performance or qualifications of staff, train staff,or make business decisions affecting the hospital and its services.
Other possible uses and disclosures of your health information to you or others:
- When required by law
- To respond to a threat to health or safety
- To report abuse or neglect
- To report exposure to communicable diseases
- Public health activities
- Health oversight activities
- Judicial and administrative proceedings
- Law enforcement
- National security
- Coroners and funeral directors
- Research Workers' Compensation
- Appointments and services
- Fundraising (If you do not want to receive communications about fundraising, please notify the Privacy Officer identified below).
- Business associates
- Inmates or persons in police custody
- Organ donation
II. Uses And Disclosures Of Information That We May Make Unless You Object.
We may use and disclose protected health information in the following instances without your written authorization unless you object. To object, please notify the Privacy Officer identified below.
Persons Involved in Your Health Care. Unless you object, we may disclose protected health information to a member of your family, relative, close friend, or other person identified by you who is involved in your health care or the payment for your health care. We will limit the disclosure to the protected health information relevant to that person’s involvement in your health care or payment.
Notification. Unless you object, we may use or disclose protected health information to notify a family member or other person responsible for your care of your location and condition. Among other things, we may disclose protected health information to a disaster relief agency to help notify family members.
III. Uses and Disclosures of Information That We May Make With Your Written Authorization.
We will obtain a written authorization from you before using or disclosing your protected health information for purposes other than those summarized above and for most uses and disclosures of psychotherapy notes; for uses and disclosures for marketing purposes; and for uses and disclosures that involve the sale of Protected Health Information. You may revoke your authorization by submitting a written notice to the Privacy Officer identified below.
IV. Your Rights Concerning Your Protected Health Information.
You have the following rights concerning your protected health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below.
You have the right to inspect and copy your personal health information.
This means you may inspect and obtain a copy of your personal health information about you for as long as Easter Seals-Goodwill has access to it. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and personal health information that is subject to law that prohibits access to personal health information.
Depending on the circumstances, a decision to deny access may be open to review. In some circumstances, you may have a right to have this decision reviewed.
Please contact the Privacy Officer below if you have questions about access to your medical record.
You have the right to request disclosure of your personal health information be restricted.
You may request that any part of your personal health information not be disclosed to family members or friends who may be involved in your care. However, Easter Seals-Goodwill is not required to agree to a restriction on disclosure if Easter Seals-Goodwill believes it is in your best interest to permit use and disclosure of your personal health information.
If Easter Seals-Goodwill agrees to the requested restriction, we may not use or disclose your personal health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your care provider. You may request a restriction by contacting the Privacy Officer below.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
We will accommodate reasonable notification requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to the Privacy Officer listed below.
You may have the right to amend your personal health information. This means you may request an amendment of personal health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the Privacy Officer listed below if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your personal health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to restrict disclosure if you pay 100% of your bill out of pocket.
If you pay for Easter Seals-Goodwill services in-full privately you may request disclosures be restricted.
You have the right to receive your medical records electronically.
You may request to receive or have your records sent to a 3rd party electronically.
IV. For More Information or to Report a Problem
If you have questions and would like additional information, you may contact John Martin, our Privacy Officer, at email@example.com or 208-373-4821.
If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer, John Martin, and Health & Human Services. All complaints must be in writing. There will be no retaliation for filing a complaint.
RECEIPT OF NOTICE OF PRIVACY PRACTICES
Participant Name: _______________________________________
My signature on this form acknowledges that I have received a copy of Easter Seals-Goodwill Northern Rocky Mountain, Inc., (ESGW-NRM, Inc.) Notice to Participants of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by ESGW-NRM, Inc. and of my rights with respect to my health information.
I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.