Notice of Privacy Practices for Protected Health Information

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 GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions or wish to receive additional information about the matters covered by this Notice of Privacy Practices, please contact Shanika Mosley at (800) 826-7871.

Northwest Indiana Community Action, Corp. is required to abide by the terms of this Notice of Privacy Practices (this “Notice”). Northwest Indiana Community Action, Corp. reserves the right to change the terms of this Notice at any time. The revised Notice will apply to all protected health information Northwest Indiana Community Action, Corp. received or created in the past as well as all protected health information Northwest Indiana Community Action, Corp. receives or creates in the future. A current copy of the Notice will be posted in each of our 6 offices and over our web site. The effective date of this Notice of Privacy Procedures is set forth on the first page of this Notice. If this Notice has been changed since your last appointment, Northwest Indiana Community Action, Corp. will provide a copy of the current Notice when the care manager visits you.. Additionally, you may obtain a copy of the current Notice by calling your care manager and requesting that one be sent to you in the mail or by asking for one when you are in the office. 

Your “protected health information” consists of all individually identifiable information which is created or received by Northwest Indiana Community Action, Corp. and which relates to your past, present or future physical or mental health  condition, the provision of health care to you or the past, present or future payment for health care provided to you.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WHICH

YOUR CONSENT OR AUTHORIZATION IS NOT REQUIRED

 

  1. Treatment: Northwest Indiana Community Action, Corp. will use and disclose your protected health information to provide, coordinate or manage your health care and related services by Northwest Indiana Community Action, Corp. and other health care providers, including consulting with other health care providers about your health care or referring you to another health care provider for treatment. For example, Northwest Indiana Community Action, Corp. will disclose your protected health information to a home health agency to ensure that the agency has the necessary information needed to serve you.
  2. Payment: Northwest Indiana Community Action, Corp. will use and disclose your protected health information, as needed, to obtain payment for the health care Northwest Indiana Community Action, Corp. provides to you.. When Northwest Indiana Community Action, Corp. performs an assessment of your needs for in-home services such as home health aide service, the assessment process is considered a health care service. Northwest Indiana Community Action, Corp. bills Medicaid and other funding sources for health care services provided to you.  In order to receive payment Northwest Indiana Community Action, Corp. will disclose protected health information.
  3. Health Care Operations: Northwest Indiana Community Action, Corp. may use or disclose your protected health information in order to support the business activities of Northwest Indiana Community Action, Corp. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, conducting training programs in which students provide assessment under the supervision of one of Northwest Indiana Community Action, Corp.’s skilled care managers, business planning and development and business management and general administrative activities. For example, Northwest Indiana Community Action, Corp. may use Protected Health Information to track trends in clients’ conditions and care. . Additionally, Northwest Indiana Community Action, Corp. may use your protected health information to help ensure that all in-home service providers provide the highest quality health care.
  4. Appointment Reminders: Northwest Indiana Community Action, Corp. may use or disclose your protected health information in order to contact you and remind you of a scheduled appointment.
  5. Treatment Alternatives: Northwest Indiana Community Action, Corp. may use or disclose your protected health information to inform you about treatment alternatives.
  6. Health Related Benefits and Services: Northwest Indiana Community Action, Corp. may use and disclose your protected health information to inform you about health-related benefits and services that may be of interest to you.
  7. Fundraising Activities: Northwest Indiana Community Action, Corp. may use or disclose your protected health information to raise funds for Northwest Indiana Community Action, Corp. If you do not wish to be contacted for fund raising purposes, please contact the Director of Planning and Development (219) 794-1829.
  8. Others Involved in Your Health Care and Disaster Relief: Unless you object, Northwest Indiana Community Action, Corp. may disclose to a family member, other relative, close personal friend or any other person identified by you protected health information related to that person’s involvement in your health care or payment related to your health care. Northwest Indiana Community Action, Corp. may also use or disclose to a person responsible for your care your protected health information that relates to your location, general condition or death. If the opportunity for you to agree or object to any such disclosure cannot be provided due to emergency circumstances, Northwest Indiana Community Action, Corp. will make these disclosures if they are in your best interests. Additionally, Northwest Indiana Community Action, Corp. may disclose protected health information relating to your location, general condition or death to any public or private entity authorized to assist in disaster relief efforts.
  9. Public Health: Northwest Indiana Community Action, Corp. may disclose your protected health information to a public health authority authorized to collect such information for the purpose of:
  10. preventing or controlling disease, injury or disability;
  11. reporting disease or injury;
  12. reporting vital events such as births or deaths;
  13. conducting public health surveillance, public health investigations and public health interventions; or
  14. at the direction of a public health authority, to an official of a foreign government agency acting in collaboration with a public health authority; or
  15. reporting child abuse or neglect.
  16. Food and Drug Administration: Northwest Indiana Community Action, Corp. may disclose your protected health information to a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for the purpose of activities related to the quality, safety or effectiveness of FDA regulated products.
  17. Communicable Diseases: Northwest Indiana Community Action, Corp. may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of spreading a disease or condition.
  18. Employer: In certain circumstances Northwest Indiana Community Action, Corp. may disclose your protected health information to your employer if Northwest Indiana Community Action, Corp. is providing health care to you at the request of your employer.
  19. Abuse, Neglect or Domestic Violence: Northwest Indiana Community Action, Corp. may disclose your protected health information to a government authority authorized to receive reports of abuse, neglect or domestic violence if Northwest Indiana Community Action, Corp. reasonably believes that you are a victim of abuse, neglect or domestic violence. Any such disclosure will be made (1) to the extent it is required by law, (2) to the extent that the disclosure is authorized by statute or regulation and Northwest Indiana Community Action, Corp. believes the disclosure is necessary to prevent serious harm to you or other potential victims or (3) if you agree to the disclosure.
  20. Health Oversight Activities: Northwest Indiana Community Action, Corp. may disclose your protected health information to a health oversight agency for any oversight activities authorized by law, including audits; investigations; inspections; licensure or disciplinary actions; civil, criminal or administrative actions or proceedings; or other activities necessary for the oversight of the health care system, government benefit programs, compliance with government regulatory program standards or compliance with applicable civil rights laws.
  21. Judicial and Administrative Proceedings: Northwest Indiana Community Action, Corp. may, upon certain conditions, disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, a subpoena, discovery request, or other lawful process.
  22. Law Enforcement Purposes: Northwest Indiana Community Action, Corp. may disclose your protected health information for law enforcement purposes to a law enforcement official in certain circumstances.
  23. Coroners, Medical Examiners and Funeral Directors: Northwest Indiana Community Action, Corp. may disclose your protected health information to a coroner or medical examiner for the purpose of identifying you, determining a cause of death or other duties authorized by law.
  24. Medical Research: Northwest Indiana Community Action, Corp. may disclose your protected health information for research purposes, provided that an institutional review board authorized by law or a privacy board waives the authorization requirement and provided that the researcher makes certain representations regarding the use and protection of the protected health information to be disclosed.
  25. Serious Threat to Health or Safety: Northwest Indiana Community Action, Corp. may disclose your protected health information, in a manner which is consistent with applicable laws, if the disclosure is necessary to prevent or lessen a serious threat to health or safety or the information is necessary to apprehend an individual.
  26. National Security and Protection of the President and Others: Northwest Indiana Community Action, Corp. may disclose your protected health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence and other national security activities authorized by law. Additionally, Northwest Indiana Community Action, Corp. may disclose your protected health information to authorized federal officials for the provision of protective services to the President, foreign heads of state, or other people authorized by law and to conduct investigations authorized by law.
  27. Inmates: Northwest Indiana Community Action, Corp. may disclose your protected health information to a correctional institution or a law enforcement official having lawful custody of you if the correctional institution or law enforcement official represents that the information is necessary under specific circumstances.
  28. Workers’ Compensation: Northwest Indiana Community Action, Corp. may disclose your protected health information as authorized by, and in compliance with, laws relating to workers’ compensation and other similar programs established by law that provide benefits for work-related illnesses and injuries without regard to fault.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any use or disclosure of your protected health information that is not listed above will be made only with your written authorization. You have the right to revoke your authorization at any time, except to the extent that Northwest Indiana Community Action, Corp. has already used or disclosed your protected health information in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
  1. Restriction of Use and Disclosure: You have the right to request that Northwest Indiana Community Action, Corp. restrict the protected health information Northwest Indiana Community Action, Corp. uses and discloses in carrying out treatment, payment and health care operations. You also have the right to request a restriction of the protected health information Northwest Indiana Community Action, Corp. discloses to a family member, other relative or any other person identified by you, which is relevant to such person’s involvement in your treatment or payment for your treatment. NORTHWEST INDIANA COMMUNITY ACTION, CORP. IS NOT OBLIGATED TO AGREE TO ANY RESTRICTION THAT YOU REQUEST. If Northwest Indiana Community Action, Corp. agrees to a restriction, however, Northwest Indiana Community Action, Corp. may only disclose your protected health information in accordance with that restriction, unless the information is needed to provide emergency health care to you.

If you wish to request a restriction on the use and disclosure of your protected health information, please send a written request to the Privacy Officer which specifically sets forth (1) whether you are restricting the use or the disclosure of your protected health information, (2) what protected health information you wish to limit, and (3) to whom you wish the limits to apply. Northwest Indiana Community Action, Corp. will not ask why you are requesting the restriction. The Privacy Officer will review your request and notify you whether or not Northwest Indiana Community Action, Corp. will agree to your requested restriction.  Northwest Indiana Community Action, Corp. reserves the right to terminate its agreement to a restriction by notifying you.  The restriction will no longer apply to protected health information obtained after the revocation of the restriction.

  1. Confidential Communications: You have the right to request that you receive communications of your protected health information from Northwest Indiana Community Action, Corp. in alternative means or at alternative locations. Northwest Indiana Community Action, Corp. will accommodate all reasonable requests. To request that Northwest Indiana Community Action, Corp. make communications of your protected health information by alternative means or at alternative locations, please send a written request to the Privacy Officer setting forth the alternative means by which you wish to receive communications or the alternative location at which you wish to receive such communications. Northwest Indiana Community Action, Corp. will not ask why you are making such a request. When appropriate, Northwest Indiana Community Action, Corp. may condition the provision of a reasonable accommodation upon receiving information relating to how payment, if any, will be received.
  2. Access to Protected Health Information: You have the right to inspect and obtain a copy of your protected health information that Northwest Indiana Community Action, Corp. maintains in a designated record set, for so long as that protected health information is maintained in a designated record set. A “designated record set” is a group of records maintained by or for Northwest Indiana Community Action, Corp. which includes medical records, case management records, billing records and records used in whole or in part to make decisions about you. You do not have the right to inspect or copy psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or information that Northwest Indiana Community Action, Corp. is otherwise prohibited by law from disclosing.

If you wish to inspect or obtain a copy of your protected health information, please send a written request to the Privacy Officer. If you request a copy of your protected health information, Northwest Indiana Community Action, Corp. may charge a fee for the cost of copying and mailing the information.

Northwest Indiana Community Action, Corp. may, for certain limited reasons, deny your request to inspect or obtain a copy of your protected health information. If Northwest Indiana Community Action, Corp. denies your request, you may be entitled to a review of that denial. If you are entitled to a review and you wish to have Northwest Indiana Community Action, Corp.’s decision reviewed, please contact the Privacy Officer. The Privacy Officer will designate a licensed health care professional to review your request. This reviewing health care professional will not have participated in the original decision to deny your request. Northwest Indiana Community Action, Corp. will comply with the decision of the reviewing health care professional.

  1. Amending Protected Health Information: You have the right to request that Northwest Indiana Community Action, Corp. amend your protected health information in a designated record set for so long as that information exists in a designated record set. To request that an amendment be made to your protected health information, please send a written request to the Privacy Officer. Your written request must provide a reason that supports the requested amendment.

Northwest Indiana Community Action, Corp. may deny your request if it does not contain a reason that supports the requested amendment. Additionally, Northwest Indiana Community Action, Corp. may deny your request to have your protected health information amended if Northwest Indiana Community Action, Corp. determines that (1) the information was not created by Northwest Indiana Community Action, Corp., unless the person or entity that created the information is no longer available to make the amendment; (2) the information is not part of a designated record set; (3) the information is not available for your inspection; or (4) the information is accurate and complete.

  1. Accounting of Disclosures of Your Protected Health Information: You have the right to request a listing of certain disclosures of your protected health information made by Northwest Indiana Community Action, Corp. during the period of up to six (6) years prior to the date on which you make your request. Any accounting you request will not include (1) disclosures made to carry out treatment, payment or health care operations; (2) disclosures made to you; (3) disclosures made pursuant to an authorization given by you; (4) disclosure’s made to other people involved in your care or made for notification purposes; (5) disclosures made for national security or intelligence purposes; (6) disclosures made to correctional institutions or law enforcement officials; or (7) disclosures made prior to April 14, 2003. The right to receive an accounting is subject to certain other exceptions, restrictions and limitations set forth in applicable statutes and regulations.

To request an accounting of the disclosures of your protected health information made by Northwest Indiana Community Action, Corp., please send a written request to the Privacy Officer. Your written request must set forth the format in which you want the accounting (i.e., hard copy, electronically) and the period for which you wish to receive an accounting. Northwest Indiana Community Action, Corp. will provide one free accounting during each twelve (12) month period.  If you request additional accountings during the same twelve (12) month period, you will be charged for all costs Northwest Indiana Community Action, Corp. incurs in preparing and providing that accounting. Northwest Indiana Community Action, Corp. will inform you of the fee for each accounting in advance and will allow you to modify or withdraw your request in order to reduce or avoid the fee.

  1. Obtaining a Copy of this Notice: You have the right to request and receive a paper copy of this Notice of Privacy Practices from Northwest Indiana Community Action, Corp. at any time.
COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with Northwest Indiana Community Action, Corp. or with the Secretary of Health and Human Services.  To file a complaint with Northwest Indiana Community Action, Corp., please contact John Hamlin at (800) 826-7871.  All complaints must be submitted in writing.

Northwest Indiana Community Action, Corp.  WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.

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