NOTICE OF 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.
Each time you visit or communicate with the Liberty County Indigent Health Care Office the staff makes a record of this communication. Typically, this record contains information needed to determine and/or continue eligibility, i.e., residency, household status, income, potential eligibility for other programs. However, your files also contain Protected Health Information. Protected Health Information is information created or received by a health care provider, health plan, employer, or health care clearinghouse that relates to your past, present, or future physical or mental health or condition; the provision of health care to you; or the past, present or future payment for the provision of health care to you and that identifies you or with respect to which there is a reasonable basis to believe the information can be used to identify you. Liberty County Indigent Health Care Office is required by the privacy regulation issued under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to maintain the privacy of your Protected Health Information and to provide you with notice of its legal duties and privacy practices with respect to your Protected Health Information. This document is notice to you of Liberty County Indigent Health Care Office’s privacy practices. Liberty County Indigent Health Care Office is required to abide by the terms of the notice currently in effect.
Indigent Health Care Office caseworkers and business associates contracted to maintain your health case records are usually the only individuals with access to these records. However, we may use or disclose your Protected Health Information without your written authorization for the following reasons:
Treatment: For example, Liberty County Indigent Health Care Office must disclose diagnosis and test results from the referring primary care physician When Liberty County Indigent Health Care Office obtains appointments or authorizes payments with specialty clinics.
Payment: For example, in order to pay for direct care, Liberty County Indigent Health Care Office must have dates of service, ICD-9 diagnosis, and CPT procedure codes on all bills.
Health Care Operations: For example, in coordinating with other agencies to provide service to our clients, Liberty County Indigent Health Care Office provides identification information and medical history.
This office does not, however, keep a copy of your medical records. These are kept by your treating physicians/facilities and would have to be requested from them. Our office only maintains your eligibility file, which also includes billing information.
Your Privacy Rights Regarding Protected Health Information
Your eligibility records and the Protected Health Information contained therein are the physical property of Liberty County Indigent Health Care Office who collected it. However, you have the following rights with respect to your own Protected Health Information:
· The right to request restrictions on uses and disclosures of your Protected Health Information to family members or personal representatives as otherwise permitted by law or to carry out treatment, payment, or health care operations. Liberty County Indigent Health Care Office is not required to agree to the requested restriction. If Liberty County Indigent Health Care Office agrees to a restriction, it will not use or disclose your Protected Health Information in violation of the restriction. Either you or Liberty County Indigent Health Care Office has the right to terminate an agreed upon restriction at any time. A request for a restriction on the uses and disclosures of your Protected Health Information must be in writing and must provide adequate detail of the restriction you are requesting.
· The right to receive confidential communications of your Protected Health Information by alternative means or at an alternative location (for example, at an address other than your home address) if you provide a clear statement that the disclosure of all or part of your Protected Health Information could endanger you.
· The right to inspect and copy your Protected Health Information except for the following:
(i) Psychotherapy notes;
(ii) Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and
(iii) Protected Health information that is subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. 263a, to the extent the provision of access would be prohibited by law or is exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant 42 CFR 493.3(a)(2).
Requests to inspect and copy Protected Health Information must be in writing and signed by you or by your representative. If Liberty County Indigent Health Care Office denies a request for access to Protected Health Information, in whole or in part, it will notify you in writing of the denial. If we grant access, we will tell you what, if anything, you have to do to get access. We reserve the right to charge a reasonable, cost-based fee for making copies.
·
The right to request an amendment of your
Protected Health Information. Such
request must be in writing and must provide a reason to support the requested
amendment. Liberty County Indigent
Health Care Office may deny a request for amendment of Protected Health
Information. If it does so, it will
notify you in writing of the reason for the denial. Requests for amendment of Protected Health
Information should be directed to: Donna
Burt, Director, Liberty County Indigent Health Care Office,
(i) Disclosures to carry out treatment, payment and health care operations;
(ii) Disclosures to you of your own Protected Health Information;
(iii) Disclosures incident to a use or disclosure otherwise permitted or required by law;
(iv) Disclosures made pursuant to an authorization signed by you;
(v) Disclosures to persons involved in your care or for other authorized notification purposes;
(vi) Disclosures for national security or intelligence purposes;
(vii)Disclosures to correctional institutions or law enforcement officials as required or authorized by law;
(viii)Disclosures as part of a limited data set; or
(ix) Disclosures made prior to
· The right to receive a copy of this Notice of Privacy Practices upon request. The law requires us to ask you to acknowledge receipt of your copy.
We will not disclose your Protected Health Information except
as described in this notice without your written authorization. Your written authorization may be revoked by
you in writing at any time by sending a written notice of revocation to Donna
Burt, Director, Liberty County Indigent Health Care Office,
How to Get More Information or to File a
Complaint
If you have any questions and/or would like additional information, you may contact the Director of the Liberty County Indigent Health Care Program at 936-336-4693 or 281-593-8428.
If you believe your privacy rights have been violated,
you may file a complaint with
Complaints to the Secretary of U.S. Department of Health and Human Services must be in writing, must specify the entity that is the subject of the complaint, and must describe the acts or omissions believed to be in violation of your privacy rights.
Liberty County Indigent Health Care Office will not intimidate or retaliate against any person who files a complaint about the treatment of his or her Protected Health Information.
RESERVES THE RIGHT TO CHANGE
ITS PRIVACY PRACTICES AND TO MAKE THE NEW PROVISIONS
EFFECTIVE FOR ALL PROTECTED
HEALTH INFORMATION WE MAINTAIN.
SHOULD WE CHANGE OUR PRIVACY PRACTICES,
WE WILL MAIL A REVISED NOTICE TO THE
ADDRESS
YOU HAVE SUPPLIED US ON YOUR APPLICATION.
This notice is effective on
Please verify by signing the attached that you have received a copy of this NOTICE of PRIVACY PRACTICES.