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.
Texas
Home Health of America, L.P. and Texas Home Health Skilled Services,
L.P. (together “Texas Home Health”) are affiliated
covered entities under the federal regulations regarding privacy of
health information and, as such, are issuing this Notice of Privacy
Practices jointly. We are providing this Notice of Privacy Practices
because the privacy of your health information is very important to
you and to us, and in compliance with federal regulations.
By “your health
information” we mean the information that we maintain that
specifically identifies you and your health status.
Summary
This Notice describes how we
use your health information within Texas Home Health and disclose it
outside Texas Home Health, and why.
The Notice covers:
Uses or Disclosures Which Do Not Require Your Written Authorization
Treatment, Payment, and Health Care Operations
We use or disclose your
health information to carry out your treatment; to obtain payment for
your treatment; and to conduct health care operations. For example:
For treatment, we use your health information to plan,
coordinate, and provide your care. We disclose your health
information for treatment purposes to physicians and other health
care professionals outside our agency who are involved in your care.
For payment, we use your health information to prepare
documentation required by your insurance company or HMO or by
Medicare or Medicaid. We disclose that part of your health
information that these organizations require in order to pay us.
For health care
operations, we use or disclose your health information, for
example, to improve the quality of our services, to plan better ways
of treating patients, and to evaluate staff performance, and to our
business associates for health care operations or payment purposes.
To confirm our visits to your home or other appointments
For treatment, we may leave your care plan and small
portions of your chart in your home for use by our staff in
providing treatment to you.
Uses
or Disclosures of Your Health Information to Which You May Object
We may use or disclose your
health information for the following purposes, unless you ask us not
to.
If you object to our use of
your health information for any of these purposes, please contact the
Privacy Officer (as shown on page 5).
Uses or
Disclosures Required or Permitted By Law
Where we are required or
permitted by law to do so, we may use or disclose your health
information in the following circumstances without your written
authorization.
· Federal government
investigation, when required by the Secretary of Health and Human
Services to investigate or determine our compliance with federal
regulations regarding privacy of health information.
· Federal,
state or local law requirements.
· Public
health activities, for example to report communicable diseases or
death; or for matters involving the Food and Drug Administration.
· Reporting
of abuse, neglect or domestic violence.
· Health oversight
activities by a health oversight agency. (A health oversight agency
is an organization authorized by the government to oversee
eligibility and compliance and to enforce civil rights laws.)
· Judicial or administrative
proceedings, for example responding to a court order or subpoena.
· Law
enforcement purposes, for example to report certain types of wounds
or other physical injuries or to identify or locate a suspect,
fugitive, material witness, or missing person.
· Use by
coroners, medical examiners, or funeral directors.
· Facilitating
organ, eye, or tissue donation.
· Research,
provided that very strict controls are enforced.
· Averting
a serious threat to your health or safety or that of the public.
· Specialized
government functions such as military or veterans’ affairs;
national security, and intelligence activities.
· Workers'
compensation.
Uses
or Disclosures Which Require Your Written Authorization
Your written authorization,
which you may revoke (in writing), is required if we use or disclose
your health information for any other purpose, in particular:
· Our use of psychotherapy
notes beyond treatment, payment, and health care operations.
· Marketing of goods or
services to you.
If you
revoke an authorization, the revocation is only effective for uses
and disclosures after the date you revoke in writing.
Your
Rights As A Patient to Privacy Of Your Health Information
· Right to Request
Restrictions
You have the right to request restrictions on our uses and
disclosures of your health information; however we may refuse to
accept the restriction.
· Right to Request
Confidential Communications
You have the right to request that we communicate with you
confidentially, for example to speak with you only in private; to
send mail to an address you designate; or to telephone you at a
number you designate. Your request must be in writing. We
will make every attempt to honor your request, if it is reasonable.
· Right to Request Access
to Your Health Information
You have the right to request access to your health information in
order to inspect or copy it. Your request must be in writing. We
may deny your request and, if so, you may be entitled to request a
review of the denial. However, we will make every attempt to honor
your request.
· Right
to Request an Amendment of Your Health Information
You have the right to request an amendment to your health
information.
Your request must be in writing and must provide a
reason for the amendment.
We may deny your request and, if so, you
may submit a statement of disagreement.
However, we will make
every attempt to honor your request.
Your
Rights As A Patient to Privacy Of Your Health Information
(continued)
· Right
to Request an Accounting of Disclosures of Your Health Information
You have the right to request an accounting of our disclosures of
your health information. There are certain disclosures that we are
not required to include in an accounting. For example, disclosures
made to you about your own health information, disclosures made with
your authorization, and disclosures for treatment, payment, and
health care operations. We will make every attempt to honor your
request. We are not required to provide an accounting for
disclosures before April 14, 2003 or for more than 6 years prior to
the date of your request.
· Right to Obtain a Paper
Copy of this Notice
If you received this Notice electronically, you have the right to
receive a paper copy.
To exercise any
of these rights please write or telephone Privacy Officer.
Our
Duties in Protecting Your Health Information
·
We are required by law to maintain the privacy of your health
information.
· We must inform patients or
their legal representatives of our legal duties and privacy practices
with respect to health information. This Notice discharges that
duty.
· We must abide by the terms
of the Notice currently in effect.
· We reserve the right to
change the terms of this Notice and to make the new Notice provisions
effective for all health information that we maintain. At any time,
you may obtain a copy of the current notice from Privacy Officer.
Complaints,
Contact Person, Effective Date, and Acknowledgement
We do not have a rigid set of requirements for you to file a
complaint. Rather, we simply ask that you provide us with the
necessary information to properly and timely follow up on your
concerns/complaint, so that we may be able to address it in the most
proactive and effective manner.
· You may complain to us and
to the Secretary of Health and Human Services if you believe your
privacy rights have been violated.
Complaints,
Contact Person, Effective Date, and Acknowledgement (continued)
· You will not be retaliated
against for filing a complaint.
· You may file your
complaint with our agency by either writing or calling the Privacy
Officer.
Privacy
Officer
Texas Home Health
580 N. 6th Street
Silsbee, TX 77656
409-385-5228
800-392-3768
· You may file a complaint
with the Secretary of Health and Human Services by writing to:
Medical
Privacy, Complaint Division
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 509F
HHH Building
Washington, D.C. 20201
Hotline number 800-368-1019
(source: www.hhs.gov/ocr)
· For further information
you may write or call Privacy Officer at the above address or
telephone number.
· This
notice is effective April 14, 2003.
----------------------------------------------------
Acknowledgment
of Receipt of Notice
Patient
name: ________________________________
Medical Record
Number: ____________
I have received a copy of
Texas Home Health’s Notice of Privacy Practices. I further
acknowledge and agree that Texas Home Health may leave my care plan
and/or portions of my medical chart in my home for use by Texas Home
Health staff in providing treatment to me.
Signature: ______________________________________________
Date: ____________
If personal
representative: Name: ________________________________________________
Relationship to
Patient: ___________________________________________
----------------------------------------------------
Reason signature not
obtained: [For Office Use Only]
[ ] Patient too
sick to sign at this time.
[ ] Patient would
not sign.
[
] Other: ________________________________________
Name of Texas Home Health
employee attempting unsuccessfully to obtain signature:
_____________________________________________
Date: _____________________________________
