Community health council, inc Notice of Privacy Practices for Protected Health Information Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Community Health Council (CHC) is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your diagnosis and test results that may be used by a health care provider for future care or treatment. It also includes billing documents for those services. Examples of Your Health Information Used for Treatment Purposes: Client presents to CHC or CHC partner agency requesting assistance with health issues. The client information is entered to the Community Access Management computer system to facilitate resource referral CHC obtains client financial and/or insurance information from partner organization to review application for assistance CHC personnel requests additional information from partner agency to provide to a healthcare professional CHC and/or partner agency share appropriate client medical information with health care professional at time of referral. CHC obtains health information from patient to locate appropriate service provider for identified health concern CHC receives direct referral from a healthcare provider (dental office, physician office, hospital, social service agency, retirement community, etc). CHC provides volunteer driver or transportation service information about client special transportation needs Prescription is faxed and/or mailed to appropriate pharmacy Examples of Your Health Information Used for Payment Purposes: Dental treatment plan for patient, including costs, is shared between CHC and dental provider Laboratory is given client information prior to conducting the tests prescribed by physician Location of client medical appointment, as well as provider s office name and address, is given to transportation service for purpose of transporting client. Name of medication and need for medication obtained from client. Information may be shared with partner agency to obtain free samples for client. Payment to healthcare provider on behalf of client may include client name, account number and a copy of CHC authorization Payment information is recorded in the Community Access Management computer system. Copies of letters mailed to clients are forwarded to appropriate partner agency staff via ground or electronic mail Partner agency may fax and/or email a copy of payment authorization for client account Healthcare provider shares client information when contacting CHC on behalf of client to pay on existing past-due account Example of Your Information Used for Health Care Operations: CHC requests permission from client to publish  thank-you letters in newsletters, letters to State Representatives, etc. Client cases may be discussed between Community Health Council staff and Community Health Resource Specialists at partner agencies. Your Health Information Rights The health and billing records we maintain are the physical property of the Community Health Council, Inc. You have a right to: Request a restriction, in writing, on certain uses and disclosures of your health information. You will be notified within 30 days if we can accommodate your request. Be given a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") at first visit to our office, or anytime upon request. Request that you be allowed to inspect and/or obtain a copy of the protected health information we maintain on your behalf. If you wish to review your information with a staff person, please call in advance to arrange a time that is mutually convenient Request, in writing, that your health care record be amended to correct incomplete or incorrect demographic information. We may deny your request if you ask us to amend information that was not created by us, is not part of the health information kept by CHC, is not part of the information that you would be permitted to inspect and copy; or, is determined to be accurate and complete. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records; You have the right to change or revoke any previous request made for PHI If you wish to exercise any of your rights as listed, please contact the CHC Privacy Officer, 1133 College Ave, Bldg A100, Manhattan, KS 66502; (785) 539-1610 in person or in writing, during regular business hours. S/he will provide you the information necessary to exercise your rights. Our Responsibilities Community Health Council, Inc. will: Maintain the privacy of your health information as required by law Provide you with a notice of our duties and privacy practices pertaining to the information we collect and maintain about you Abide by the terms of this Notice Notify you if we cannot accommodate a requested restriction or request; and, Accommodate your reasonable requests regarding methods to communicate health information with you We reserve the right to amend, change or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You will receive a revised copy of the Notice at your next visit or you may request a copy of our  Notice by calling us or by visiting our office to obtain a copy. Website If we maintain a website with a customer service function, we will post this Notice of Privacy Practices in a prominent location. Documentation and Retention CHC will retain copies of all Notice of Privacy Practices issued for a period of six years as set forth in 45 CFR 164.530(j). Changes To This Notice We reserve the right to change this notice without prior notification. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at the Community Health Council office. The notice will contain the effective date in the document header. Acknowledgement You will be asked to provide a written acknowledgement of your receipt of this Notice of Privacy Practices. To Request Information or File a Complaint If you have questions, would like additional information or wish to report a problem regarding the handling of your information, you may contact the Privacy Officer at (785) 539-1610. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Privacy Officer. You may also file a complaint by mailing it to the Secretary of Health and Human Services, whose street address is The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Washington, D.C. 20201. We will not require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of providing services. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services. Other Disclosures and Uses Notification Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your general condition or your death Communication with Family Using our best judgment, and in the best interest of you as client, we may disclose health information to a family member, other relative, close personal friend or any other person you identify as involved in your care or in payment for such care unless you file a specific restriction. Food and Drug Administration (FDA) We may disclose to the FDA your protected health information relating to adverse events with respect to products or post-marketing surveillance information to enable product recalls. Workers Compensation If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation. Public Health As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability; or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition. Abuse & Neglect We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect. Employers Except in cases involving workers' compensation, disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer. Correctional Institutions If you are an inmate of a correctional institution, we may disclose the protected health information necessary for your health and the health and safety of other individuals to the institution or its agents Law Enforcement We may disclose your protected health information for law enforcement purposes as required by law, as required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement. Health Oversight Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order. Serious Threat To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public. For Specialized Governmental Functions We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel. Coroners, Medical Examiners and Funeral Directors We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties. Other Uses Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights." Copyright © 2000, Community Health Council. All rights reserved