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.
This privacy notice is required by new federal regulation, signed into law in
1996 known as the Health Insurance Portability and Accountability Act (HIPAA).
45 CFR §164.520 (B) (1) (I)
This notice will tell you how Foothills Gateway, Inc. (FGI) may use and disclose
protected health information about you. Protected Health Information (PHI) means any health information about you
that identifies you or for which there is a reasonable basis to believe the
information can be used to identify you. In the header above, PHI information is referred to as “medical
information.” In this notice, all
protected health information will be called “health information, or PHI.”
This notice
also will tell you about your rights and FGI’s duties with respect to health
information about you. In addition,
it will tell you how to complain to FGI if you believe we have violated your
privacy rights.
Right to Change Notice of Privacy Practices.
FGI reserves the right to change this Notice of Privacy Practices. FGI reserves the right to make the
new notice’s provisions effective for all health information that FGI maintains,
including information created or received by FGI prior to the effective date of
the new notice.
45 CFR §164.520(b)(v)(C)
HOW FOOTHILLS GATEWAY, INC. MAY USE AND DISCLOSE YOUR PROTECTED HEALTH
INFORMATION
FGI has policies in effect concerning Confidential Information, Master Records
and Access to Information. These
policies outline practices that will continue in addition to this Privacy
Notice.
The law requires FGI to have your written authorization for some uses and
disclosures. In other circumstances,
the law allows FGI to use and disclose PHI without your written authorization.
FGI may use or disclose PHI without your authorization for the purposes of
treatment, payment or health care operations
For Treatment
FGI uses health information about you to provide, coordinate, or manage the
services, supports, and health care you receive from FGI and other Program
Approved Service Agencies. FGI may
disclose health information about you to doctors, nurses, psychologists, social
workers, agency staff, consultants, volunteers and other persons who are
involved in supporting you or providing care or treatment. FGI may consult with other health
care providers, and as part of the consultation share your health information
with them. FGI staff may discuss
your PHI to develop and carry out your individual plan. FGI staff may share information to
coordinate needed services such as medical tests, transportation to a doctor or
therapy. FGI staff may need to
disclose health information to entities outside FGI (for example, another
provider or a state or local agency) to obtain new services for you.
For Payment
FGI may use and disclose PHI about you so we can be paid for the services FGI
provides. This can include billing a
third party payor, such as Medicaid or other state agency (for example,
Developmental Disabilities Services). FGI needs to provide the state Medicaid
program and billing agent information about the services FGI provides to you so
we will be reimbursed for those services. FGI also may need to provide the state Medicaid program with information
to ensure you are eligible for the medical assistance program.
For Health Care Operations
FGI uses and discloses health information about you for our own operations. This is necessary for us to operate
FGI and to maintain quality for our consumers. For example, FGI may use PHI about you to review the services provided
and the performance of our employees supporting you. FGI may disclose PHI about you to
train staff and volunteers. FGI may
use the information to study ways to more efficiently manage the organization,
for accreditation or licensing activities, or for the quality assurance survey
process.
Certain Uses and Disclosures Do Not Require Your Written Authorization
The law allows FGI
to disclose PHI without written authorization in the following circumstances.The amount of information disclosed
will be restricted to the minimum amount
necessary to accomplish the intended purpose of the disclosure.
When Required by Law FGI discloses PHI when required to do
so by federal, state or local law.
To Law Enforcement FGI may release PHI (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) about the victim of
a crime if we are unable to obtain the person’s authorization, (d) about a death
that may be due to criminal conduct, (e) about criminal conduct at the facility,
(f) and in emergency circumstances, to report a crime, its location or victims,
or the identity, description or location of the person who committed the crime.
Victims of Abuse, Neglect,
Domestic Violence FGI may disclose PHI about you to a
government authority authorized by law to receive reports of abuse, neglect or
domestic violence. This disclosure
will occur as required by law or regulations for entities serving
developmentally disabled individuals.
For Public Health Activities FGI discloses PHI to report suspected
abuse, the occurrence of certain diseases, or adverse reactions to a drug or
medical device.
To Health Oversight Agencies FGI will provide PHI as requested to
regulatory agencies with the authority to audit or investigate our operations. Documentation of a review of records
is noted in the master record for each individual.
For Lawsuits and Disputes If you are
involved in a lawsuit or dispute, FGI may disclose your PHI in response to a
subpoena or other lawful request, but only if efforts have been made to tell you
about the request or to obtain a court order that will protect the PHI
requested.
To Coroners, Medical Examiners and Funeral Directors FGI may disclose PHI about you to a
coroner, or medical examiner for purposes or identifying a deceased person,
determining a cause of death, or to a funeral director as necessary to
facilitate their duties.
For Research By current policy, FGI does not
disclose PHI for research purposes.
To Avert a Serious Threat to Health and Safety FGI may disclose your PHI to someone
who can help prevent a serious threat to your health and safety or the health
and safety of another person or the public.
Uses and
Disclosures that Require Foothills Gateway, Inc. to Give You the Opportunity to
Object.
How FGI will Contact You
Unless you indicate otherwise, FGI will contact you either by mail or telephone
at your home or workplace. At either
location, FGI may leave messages on the answering machine or voice mail. If you wish for FGI to communicate
with you in a certain way, or at a certain location, you should complete a
Request for Confidential Communications form available from your Case Manager.
Appointment Reminders
FGI uses and discloses PHI about you to contact you to remind you of an
appointment for treatment or services.
Treatment and Service Alternatives
FGI uses your PHI to contact you about treatment and service alternatives that
may be of interest or benefit to you.
Health Related Benefits and Services
FGI may use and disclose PHI about you to contact you about health related
benefits and services.
Public Information and Communications
FGI will not use or disclose PHI about you for the purposes of public
information without written authorization.
Fundraising
FGI will not use or disclose PHI about you in order to promote public awareness,
support and funding without written authorization.
Disclosures to Family and Others
With written authorization, FGI will disclose PHI about you to parents, family
members, relatives or any other person identified by you. The information disclosed will be
relevant to that persons involvement with the services and supports you receive
or payment for those services and supports.
Other Uses and Disclosures
Other uses and disclosures will be made only with your written authorization.
You may revoke such an authorization at any time by notifying your Case Manager
in writing of your desire to withdraw the authorization.
YOUR RIGHTS RELATED TO YOUR PROTECTED HEALTH INFORMATION
Right to Request Restrictions
You have the right to ask FGI to limit how we use and disclose your Protected
Health Information, for treatment, payment, or health care operations as long as
you are not asking FGI to limit uses and disclosures that FGI is required or
authorized to make, or to place limits on any of the disclosures described
above. Requests for restrictions
must be submitted in writing to the Privacy Officer at FGI. FGI is not required to agree with
your request. If FGI agrees, we will
acknowledge the request in writing and abide by the agreement except when you
require emergency treatment.
Right to Choose How We Communicate With You
You have the right to ask that FGI send information to you at a specific
address, (at your workplace rather than at home) or in a specific manner (for
example: regular mail, or never by telephone). FGI will agree to your request as long as it would not be disruptive to
our operations to do so. You must
make any such request in writing, addressed to the Privacy Officer.
Right to See and Obtain a Copy of your Protected Health Information
Except for limited circumstances, you may look at and copy your PHI. Your case manager will assist you in
this process. If you ask FGI to copy
your PHI, we will charge you $.05 for each page.
Right to Amend or Update your Protected Health Information
If you believe the Protected Health Information FGI has about you is incomplete
or incorrect, you may ask FGI to amend it. Any such request must be made in writing addressed to the Privacy
Officer. You must tell FGI why you
think the amendment is appropriate.
FGI will act on your request with 60 days and will inform you in writing as to
whether the amendment will be made or denied. If we agree to the amendment, FGI will ask you who needs to be notified
of the amendment. FGI will deny your
request if you ask to amend information that (a) was not created by FGI, (b) is
not part of the PHI FGI keeps about you, (c) is not part of the PHI you are
allowed to see and copy, or (d) is determined by FGI to be accurate and
complete. If FGI denies the
requested amendment, FGI will notify you in writing and include information on
how to submit a statement of disagreement or complaint, or how to request
inclusion of your original amendment request in your PHI.
Right to An Accounting of the Disclosures.
You have the right to receive an accounting of disclosures of PHI about you. The accounting may be up to six (6)
years prior to the date on which you request the accounting but not before April
14, 2003.
Certain types of disclosures are not included in such an accounting:
- Disclosures to carry out treatment, payment and health care operations.
- Disclosures of your health information made to you.
- Disclosures you have authorized.
- Disclosures for disaster relief purposes.
- Disclosures for national security or intelligence purposes.
- Disclosures to correctional institutions or law enforcement officials.
- Disclosures made prior to April 14, 2003.
To request an
accounting of disclosures, you must submit your request in writing to the
Privacy Officer at FGI. Your request
must state a time period for the disclosures. FGI will act upon your request within 60 days.
Right to a Copy of FGI Notice of Privacy Practices.
You have a right to
obtain a paper copy of the FGI Notice of Privacy Practices. You may request a copy of our Notice
of Privacy Practices at any time by contacting the Privacy Officer at FGI.
You may obtain a
copy of the FGI Notice of Privacy practices over the Internet at our website
www.foothillsgateway.org.
FOOTHILLS GATEWAY INC. DUTIES
FGI is required by
law to maintain the privacy of health information about you and to provide
individuals with notice of our legal duties and privacy practices with respect
to health information.
Complaints
You may complain to FGI and to the United States Secretary of Health and Human
Services if you believe your privacy rights have been violated by FGI.
To file a complaint with FGI, contact the Complaint Officer, at Foothills
Gateway, 301 W. Skyway Drive, Fort Collins, CO 80525. Phone (970) 226-2345. All complaints should be submitted in
writing.
To file a complaint
with the United States Secretary of Health and Human Services, send your written
complaint to him or her in care of: Office for Civil Rights, U.S. Department of
Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.
You will not be
retaliated against for filing a complaint.
Questions and Information
If you
have questions or want more information concerning this Notice of Privacy
Practices, please contact the Privacy Officer at Foothills Gateway.