LCCCAdmission Agreement: Attachment B
Revised Date: September 19, 2014
ADMISSION AGREEMENT: ATTACHMENT B
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY (HIPAA)
NOTICE OF PRIVACY PRACTICES
I. Introduction
A. Lake Charles Care Center understands that the security of your personal health information is important and we have always been committed to protecting it. Upon admission to our Facility we create a comprehensive record of the treatment, tests and services you receive (in hard copy and electronic formats) in order to provide you with the best quality care and also to comply with specific legal requirements. This notice is designed to explain the ways in which we may use and disclose your health information and applies to all records of your care generated by our Facility. It further describes the obligations we have regarding the use and disclosure of your health information.
B. We are required by law to:
maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information;
abide by the terms of the notice currently in effect;
provide individuals with a revised notice in the event the terms of the current notice are changed.
II. Uses and Disclosures
A. We may use and disclose your protected health information without consent for the following reasons:
1) TREATMENT – In order to provide you with health care treatment or services, information may be provided to doctors, nurses, technicians, therapists, or other personnel who are involved in your care. They may work at our Facility, a hospital, your doctor’s office, a lab, a pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a physical therapist treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process and increase rehabilitation time. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
2) PAYMENT – In order for the treatment and services you receive to be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give Medicare or Medicaid information about your stay so they will pay us or reimburse your stay. We may also tell your health insurance plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
3) HEALTH CARE OPERATIONS – For the operation of our health care facility and to ensure that all of our residents receive quality care. For example, we may use health information about you to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many residents to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning the identity of our residents.
4) CARE PLAN APPOINTMENTS – In order to contact you or your responsible party as a reminder that you have an appointment. Please let us know if you do not wish to have us contact you concerning your appointment or if you wish to have us use a different telephone number or address to contact you for this purpose.
5) ORGAN AND TISSUE DONATION – In order to facilitate organ or tissue donation and transplantation (if you are an organ donor) to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank.
6) AS REQUIRED BY LAW – When required by federal, state, or local law.
7) TO AVERT SERIOUS THREAT TO HEALTH OR SAFETY – In order to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure; however, would only be to someone able to help prevent the threat.
8) MILITARY AND VETERANS – As required by military command authorities or the Department of Veterans Affairs (if you are a member of the Armed Forces or separated/discharged from the military). We may also release health information about foreign military personnel to the appropriate foreign military authorities.
9) WORKERS’ COMPENSATION – For workers’ compensation or similar programs designed to provide benefits for work-related injuries or illness.
10) PUBLIC HEALTH RISKS – For public health activities, including the following:
a) to prevent or control disease, injury, or disability;
b) to report births and deaths;
c) to report child abuse or neglect;
d) to report reactions to medications or problems with products;
e) to notify people of recalls of products they may be using;
f) to notify a person who may have been exposed to a disease or may be at risk
for contracting or spreading a disease or condition;
g) to notify the appropriate government authority if we believe a resident has
been the victim of abuse, neglect, or domestic violence. We will only make
this disclosure if you agree or when required or authorized by law.
11) HEALTH OVERSIGHT ACTIVITIES – To a health oversight agency for activities authorized by law, including audits, investigations, inspections and licensure, as necessary for the government to monitor the health care system, government programs and ensure compliance with civil rights laws.
12) LAWSUITS AND DISPUTES – If you are involved in a lawsuit or dispute and in response to a court or administrative order, subpoena, discovery request, or other lawful process by someone else involved in the dispute (only if efforts have been made to tell you about the request or to obtain an order protecting the information requested).
13) LAW ENFORCEMENT – If asked to do so by a law enforcement official and:
a) in response to a court order, subpoena, warrant, summons, or similar process;
b) to identify or locate a suspect, fugitive, material witness, or missing person;
c) regarding the victim of a crime, if under certain limited circumstances, we are
unable to obtain the individual’s agreement;
d) regarding a death we believe may be the result of criminal conduct;
e) regarding criminal conduct at our Facility;
f) in emergency circumstances to report a crime, the location of a crime or
victims, or the identity, description, or location of the individual who
committed a crime.
14) CORONERS, HEALTH EXAMINERS AND FUNERAL DIRECTORS – In order to identify a deceased person or determine the cause of death and in order to carry out their duties.
15) NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES – To authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
16) PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS – To authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations.
17) INMATES – In the event you become an inmate of a correctional institution or in the custody of a law enforcement official, in order for the institution to provide health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.
III. Your Rights
A. You have the following rights regarding your protected health information:
1) RIGHT TO INSPECT AND COPY – You have the right to inspect and copy your protected health information, including health and billing records.
Requests may be submitted orally or in writing (legibly hand-written or typed) to the Administrator. A fee for the cost of copying, mailing, or other supplies and services may be charged.
2) RIGHT TO AMEND – You have the right to request that your protected health information be amended if you feel that it is incorrect or incomplete. This right extends for as long as we maintain record of the information. Requests must be submitted in writing to the Administrator and provide a reason that supports the request for amendment.
We may deny your request for amendment if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if the information:
a) was not created by us, unless the person or entity that created the information
is no longer available to make the amendment;
b) is not part of the protected health information kept by or for our Facility;
c) is not part of the information which you would be permitted to inspect or copy;
d) is accurate and complete.
3) RIGHT TO AN ACCOUNTING OF DISCLOSURES – You have the right to request a list of disclosures of your protected health information we have made, except for uses and disclosures for treatment, payment and health care operations, as previously described.
Requests must be submitted, in writing, to the Administrator and specify a time period which may not be longer than six years and not include dates before April 14, 2003. The first list of disclosures within a 12 month period will be provided free of charge. Additional lists during that period may incur a fee. We will notify you of the cost involved and you may choose to withdraw or modify your request before any fees are charged. We will mail the list of disclosures within 30 days or notify you if we are unable to comply within that time period. We will also notify you by what date we will be able to provide the list, which will not exceed a total of 60 days from the initial request.
4) RIGHT TO REQUEST RESTRICTIONS – You have the right to request restrictions or limitations on the protected health information we are allowed to use or disclose for your treatment, payment, or health care operations. You also have the right to request that information not be disclosed to someone who is involved in your care, such as a family member or friend. For example, you may request that a specific nurse be restricted from using your information or that we not disclose information to your spouse regarding a recent surgery.
We are not required to agree with your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide to you.
If we do agree with your request, we will comply unless the information is needed to provide you emergency treatment. Requests must be submitted, in writing, to the Administrator and specify the information you want restricted and to whom the restrictions will apply.
5) RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS – You have the right to request that we communicate with you regarding health matters in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail to a post office box.
Requests must be submitted, in writing, to the Administrator and must specify how or where you wish to be contacted. All reasonable requests will be honored.
6) RIGHT TO A PAPER COPY OF THIS NOTICE – You have the right to obtain a paper copy of this notice at any time. Requests may be made directly to the Administrator.
IV. Changes to this Notice
Our Facility reserves the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. If this occurs, a copy of the revised notice will be provided to you. A copy of the current notice will be posted in the Facility and display the effective date in the top right corner of the first page. In addition, each time you are admitted for treatment or other health care services, a copy of the current notice in effect will be offered to you.
V. Complaints
If you believe your privacy rights have been violated, you may file a written complaint with the Administrator. Complaints may also be filed with the Secretary of the Department of Health and Human Services. Contact information for the Department of Health and Human Services is posted in our Facility.You will not be penalized for filing a complaint.
VI. Other Uses of Health Information
We will use and disclose protected health information not covered by this notice or applicable laws only with your written permission. If you grant us permission to use or disclose protected health information under these circumstances, you may revoke that permission at any time by submitting a written revocation to the Administrator. We will not; however, be able to withdraw any disclosures already made and are required to retain our records for a specific length of time.
Acknowledgment of Receipt of Notice of Privacy Practices
I, ______, have received the Notice of Privacy Practices from
Lake Charles Care Center.
X______
Resident, Legal Representative, or Responsible Party Date
______
Nursing Facility Representative/Title Date
In lieu of resident signature, I, ______, a staff member of Lake Charles Care Center, state that ______has been provided a copy of our current Notice of Privacy Practices.
______
Nursing Facility Representative/Title Date
THE USE OF SURVEILLANCE EQUIPMENT
NON-PATIENT CARE AREAS
In order to provide our residents with an environment that is both safe and secure, we currently incorporate a video surveillance system in each of our long term care facilities. In designing these systems, we have carefully placed each camera in non-patient care areas to ensure resident privacy, dignity, and the decency to respect their personal space and activity.
PATIENT CARE AREAS
Surveillance equipment in our patient care areas for the use of monitoring the care or services provided to a resident(s) is prohibited unless approved by the Administrator and with the consent of the resident(s), and as permitted by current state law governing such issues.Violation of facility policy governing the use of surveillance equipment may result in the immediate removal of such equipment.
Acknowledgment of Notice of Use of Surveillance Equipment
I, ______, have been notified of the practices with regard to the use of surveillance equipment from Lake Charles Care Center.
X______
Resident, Legal Representative, or Responsible Party Date
______
Nursing Facility Representative/Title Date
In lieu of resident signature, I, ______, a staff member of Lake Charles Care Center, state that ______has been informed of our facility’s policy regarding the use of surveillance equipment.
______
Nursing Facility Representative/Title Date
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