Opportunities for People with Disabilities

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MANASOTA ASSOCIATION FOR RETARDED CITIZENS, INC.

RELEASE FORM FOR HIPPA

NOTICE OF MANASOTA ARC’S PRIVACY PRACTICES

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.  You have the right to obtain a paper copy of this notice upon request.

 

Who will follow this notice

 

This notice describes  Manasota ARC’s practices and that of (a) any health care professional authorized to enter information into our medical record, (b) volunteers we allow to help you while you are receiving Manasota ARC services, and (c) all Manasota ARC employees and staff.

 

Patient Health Information

 

Under federal law, your patient health information is protected and confidential, Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information.  Your health information also includes payment, billing, and insurance information.

 

Use and Disclosure of Health Information

 

Manasota ARC may use your health information for purposes of providing you treatment, obtaining payment for the services you received and for health care operations, including administrative purposes and evaluation of the quality of care that you receive.  Unless otherwise indicated, your health care information may be used or disclosed only after Manasota ARC has obtained your written consent or authorization.  Manasota ARC has established a policy to guard against unnecessary disclosure of your health information.

 

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT:

 

 1.  To Provide Treatment:    Manasota ARC will use and disclose your health information to provide you with medical treatment or service.  For example, therapist, nurses and other members of your service team will record information on your record and use it to determine the most appropriate course of care.  We may disclose their information to other health care providers who are participating in your treatment, including you primary care physician, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.

 

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2.  To Obtain Payment:    Manasota ARC will use and disclose your health information for payment purposes.  For example, we may need to obtain authorization from your support coordinator or insurance company before providing certain types of treatment.  We will submit bills and maintain records of payments from your health plan.

 

3.  To Conduct Health Care Operations:      Manasota ARC will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, and to assess the care and outcomes of your case and others like it.  Health care operations include such activities as:

  • Quality assessment and improvement activities.
  • Activities designed to improve health and reduce health care costs.
  • Protocol development, case management, and care coordination.
  • Contact health care providers and consumers with information about treatment alternatives and other related functions that do not include treatment.
  • Professional review and performance evaluation.
  • Training programs including those which students, trainees, or practitioners in health care team learn under supervision.
  • Training of non-health care professionals.
  • Accreditation certification, licensing or credentialing activities.
  • Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
  • Business planning and development including cost management and planning related analyses and formulary development.
  • Business management and general administrative activities of the agency.

 

For example, Manasota ARC may use your health information to evaluate its staff performance, combine your health information with other Manasota ARC consumers/patients in evaluating how to more effectively serve all Manasota ARC consumers, or disclose your health information to Manasota ARC staff and contracted personnel for training purposes.  Also, Manasota ARC may disclose certain information about you including your name and your general health status.

 

4.  Appointment Reminders:    We may use and disclose health information to       contact you with a reminder regarding a visit with our agency.

 

5.      Treatment Alternatives:    We may use and disclose health information to tell you about or recommend possible treatment options or alternatives.

 

6.      For Fundraising Activities:   Manasota ARC may use information about you including your name, address, phone number and the dates you received at Manasota ARC in order to contact you or your family to raise money for Manasota ARC (unless you tell us you do not want to be contacted).

 FEDERAL PRIVACY RULES ALLOW MANASOTA ARC TO USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION FOR A NUMBER OF REASONS INCLUDING THE FOLLOWING:

 

1.  Required by Law:     Manasota ARC will disclose your health information when it is required to do so by Federal, State or Local law.

 

2.  Risks to Public Health:    Manasota ARC may disclose your health information for public activities and purposes in order to :

 

  • Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death, and the conduct of public health surveillance, investigations and interventions.
  • To report adverse events, product defects, to tract products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

 

3.  To Report Abuse, Neglect, or Domestic Violence:    Manasota ARC is allowed to notify government authorities if the agency believes a consumer is the victim of abuse, neglect, or domestic violence.  Manasota ARC will make this disclosure only when specifically required or authorized by law.

 

4.  Health Oversight Activities:     Manasota ARC may disclose your health information to a health oversight agency for activities including audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary action.  Manasota ARC, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

 

5.  In Connection with Judicial and Administrative Proceedings:      Manasota ARC may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribune as expressly authorized by such order or in response to  a subpoena, discovery request, or other lawful process.

 

6.  For Law Enforcement Purposes:      Manasota ARC may disclose your health information to a law enforcement official for law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • In an emergency in order to report a crime.

 

7.  Deaths:     Manasota ARC may report information regarding death to coroners, medical examiners, funeral directors and organ donation agencies.

 

8.  Research:     Manasota ARC may, under very select circumstances, use your health information for research.  Before Manasota ARC discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.  Manasota ARC will ask your permission if any researcher will be granted access to your individually identifiable health information.

 

9.  Serious Threat to Health and Safety:     Manasota ARC may, consistent with applicable law and ethical standards of conduct, disclose your health information if the agency, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

 

10.  Military and Veterans:   If you are a member of the Armed Forces, Manasota ARC may release health information about you as required by military command authorities.  Manasota ARC may also release health information about foreign military personnel to the appropriate foreign military authority.

 

11.  National Security and Intelligence Activities:     Manasota ARC may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

 

12.  Protective Services for the President and Others:    Manasota ARC may disclose 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.

 

13.  Worker’s Compensation:     Manasota ARC may release your health information for worker’s compensation or similar programs providing benefits for work related injuries or illnesses.

 

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION    

Other than is stated above, Manasota ARC will not disclose your health information other than with your written authorization.  If you or your representative authorizes Manasota ARC to use or disclose your health information, you may revoke that authorization in writing at any time.  If you revoke your permission, Manasota ARC will no longer use or disclose health information about you for the  reasons covered by your written authorization.  You understand that Manasota ARC is unable to take back any disclosures that have already been made with your authorization, and that Manasota ARC is required by law to retain our records of the services provided to you.

 

 

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

 

You have the following rights regarding your health information that Manasota ARC maintains:

  • Right to Request Restrictions.  You have the right to request a restriction or limitation on the health information Manasota ARC uses or discloses about you for treatment, payment, or health care operations, and to request a limit on the health information Manasota ARC discloses about you to someone who is involved in your care or payment, such as a family member or friend.  Manasota ARC is not required to agree to your request.  If Manasota ARC does agree, however, the agency will comply with your request unless the information is needed to provide you with the emergency or other vital treatment.  To request restrictions, you must tell Manasota ARC (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, disclosure to your spouse.  To request restrictions, you must submit your request in writing to our Privacy Officer at the address shown below.
  • Right to Receive Confidential Communications.  You have the right to request, in writing, that Manasota ARC communicate with you in a certain way .  For example, you may ask that Manasota ARC only conduct communications pertaining to your health information with you privately with no other family members present.  Manasota ARC will not required that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
  • Right to Inspect and Obtain a Copy of your Health Information:   You have the right to inspect and receive a copy of health information about you.  Usually, this includes medical and billing records, but does include psychotherapy notes or information compiled in  reasonable anticipation of or for use in a civil, criminal or administrative action or proceeding.  To inspect and copy health information, you must submit your request in writing.  If you request a copy of your health information, Manasota ARC may charge a reasonable fee for copying and assembling costs associated with your request.
  • Right to an Accounting:   You or your representative have the right to request an accounting of disclosures of your health information made by  Manasota ARC.  This is a list of the disclosures Manasota ARC made of health information about you but does not include disclosures (a) to carry out treatment, payment or health care operations: (b) made to you: (c) to other person’s involved in your care: (d) for national security or intelligence purposes; or (e) law enforcement officials as provided by law.  The request for an accounting must be made in writing.  The request should specify the time period for the accounting and must be after April 14, 2003.  Accounting requests may not be made for periods of time in excess of six years.  Manasota ARC would provide the first accounting you request during any 12 month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.  Manasota ARC will notify you of the costs involved before completing your request, so that you will have the chance to withdraw or modify your request before any costs are incurred.

 

  • Right to Paper Copy of this Notice:   No later than the date of the first service delivery on or after January 1, 2004, a copy of this notice shall be provided to you.  You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously.  The Manasota ARC consumer or a representative may also obtain a copy of the current version of Manasota ARC’s Notice of Privacy Practices at its website:  www.manasotaarc.org.

 

OUR LEGAL DUTY

 

Manasota ARC is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices.  Manasota ARC is required to abide by terms of this Notice as may be amended from time to time.  Manasota ARC reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains.  If Manasota ARC changes its Notice, Manasota ARC will post a revised copy of the current notice at each of the Manasota ARC facilities reflecting its effective date.

 

COMPLIANTS

 

You or your personal representative have the right to express complaints to Manasota ARC and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated.  Any complaints to Manasota ARC should be made in writing to the Privacy Officer or designee.  Manasota ARC encourages you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint

 

 

EFFECTIVE DATE:

This Notice is effective January 1, 2004

 

 

If you have any questions regarding this notice,  please contact:

 

Privacy Officer or Designee at Manasota ARC

4211 36th Ave. East
Palmetto, FL  34221

Phone: (941) 721-7684 • Fax: (941) 729-3563

www.manasotaarc.org 

 

ACKNOWLEDGMENT OF PRIVACY PRACTICES

 

 

I hereby acknowledge that I have received a copy of the Manasota ARC Notice of Privacy Practices as required by Federal Law in accordance with HIPPA regulations.

 

 

 

Consumer Signature_________________________________ Date _______

EXPIRES 1 YEAR FROM DATE SIGNED

 

 

Parent/Legal Guardian (if applicable) ____________________ Date_______

EXPIRES 1 YEAR FROM DATE SIGNED

 

 

 

 

Reason Consumer/Personal Representative failed to sign:

 

 

 

 

 

 

 

 

 

Agency Representative _______________________________ Date _______

     EXPIRES 1 YEAR FROM DATE SIGNED

 

 

 

 

 

 

 

 

 

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