FOOTHILLS
GATEWAY, INC.
NOTICE OF PRIVACY
PRACTICES
Effective 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.
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 payer, 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 person’s
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.
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:
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.
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.
If you
have questions or want more information concerning this Notice of Privacy
Practices, please contact the Privacy Officer at Foothills Gateway.